Or. Admin. R. 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 tasks of an
activity every time the activity is attempted.
(2) MAXIMUM SERVICE PERIOD HOURS FOR ADL.
(a) The planning process uses the following
maximum hours limitations for each service period for ADL tasks. Maximum hours
in each assistance level are not guaranteed. Hours authorized must be based on
the service needs of an individual as determined by the Case Manager during the
person-centered service planning process.
(b) For in-home benefit plans created after
May 21, 2018, the following maximums apply:
(A) Eating:
(i) Minimal assistance, three
hours.
(ii) Substantial assistance,
nine hours.
(iii) Full assistance,
fourteen hours.
(B)
Dressing and Grooming:
(i) Minimal assistance,
two hours.
(ii) Substantial
assistance, seven hours.
(iii) Full
assistance, nine hours.
(C) Bathing and Personal Hygiene:
(i) Minimal assistance, five hours.
(ii) Substantial assistance, seven
hours.
(iii) Full assistance,
twelve hours.
(D)
Mobility:
(i) Minimal assistance, five
hours.
(ii) Substantial assistance,
seven hours.
(iii) Full assistance,
twelve hours.
(E)
Elimination (Toileting, Bowel, and Bladder):
(i) Minimal assistance, five hours.
(ii) Substantial assistance, nine
hours.
(iii) Full assistance,
fourteen hours.
(F)
Cognition:
(i) Minimal assistance, three
hours.
(ii) Substantial assistance,
six hours.
(iii) Full assistance,
twelve hours.
(c) 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 the tasks associated with
the activity of daily living as determined by a service assessment applying the
parameters in OAR 411-015-0006.
(d)
The Case Manager may authorize fewer hours than the maximum number of hours in
any or all ADL tasks based on their assessment of the individual's unmet need.
The Case Manager must document the reason for authorizing fewer hours than the
maximum number of hours allowed. The case manager may authorize fewer hours
than the maximum for any of the following defined reasons:
(A) Reduced frequency or duration of an ADL
need.
(B) Durable medical equipment
or home modification reduces need for assistance.
(C) Individual preference.
(D) Natural supports.
(E) Provided or funded by another
agency.
(e) For
households with two or more eligible individuals, each individual's ADL service
needs must be considered separately.
(f) 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 SERVICE PERIOD HOURS FOR IADL.
(a) The planning process uses the following
limitations for time allotments for IADL tasks. Maximum hours in each
assistance level are not guaranteed. Hours authorized must be based on the
unmet service needs of an individual as determined by the case manager during
the person-centered service planning process.
(A) Medication Management:
(i) Minimal assistance, one hour.
(ii) Substantial assistance, two
hours.
(iii) Full assistance, five
hours.
(B)
Transportation:
(i) Minimal assistance, one
hour.
(ii) Substantial assistance,
one hour.
(iii) Full assistance,
two hours.
(C) Meal
Preparation:
(i) Minimal assistance:
(I) Breakfast, one hour.
(II) Lunch, one hour.
(III) Supper, two hours.
(ii) Substantial assistance:
(I) Breakfast, two hours.
(II) Lunch, two hours.
(III) Supper, three hours.
(iii) Full assistance:
(I) Breakfast, five hours.
(II) Lunch, five hours.
(III) Supper, six hours.
(D) Shopping:
(i) Minimal assistance, one hour.
(ii) Substantial assistance, two
hours.
(iii) Full assistance, three
hours.
(E) Housekeeping
and Laundry:
(i) Minimal assistance, two
hours.
(ii) Substantial assistance,
five hours.
(iii) Full assistance,
nine 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 need in medication
management and transportation must be authorized separately. Payment is made
for the individual with the highest of the allotments in meal preparation,
shopping, and housekeeping and laundry and a total of two additional IADL hours
per service period 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.
Hours authorized must incorporate the frequency and the duration of the tasks
within each instrumental activity of daily living. For housekeeping, the size
of the home may be used to reduce the hours. For meal preparation, hours must
be reduced if an individual is receiving Medicaid home delivered
meals.
(e) The Case Manager may
authorize fewer hours than the maximum number hours in any or all IADLs based
on their assessment of the individual's unmet need. The Case Manager must
document the reason for authorizing fewer hours than the maximum hours. The
Case Manager may reduce hours for any of the following reasons:
(A) Reduced frequency or duration of an IADL
need.
(B) Durable medical equipment
or home modification reduces need for assistance.
(C) Individual preference.
(D) Natural supports.
(E) Provided by or funded by another
agency.
(F) Small living
space.
(4)
When one or more eligible individuals are living in the same household and
receiving in-home services, the total number of hours authorized for ADLs and
IADLs may not exceed 24 hours within any 24-hour period in the same household
unless an exception is granted as described in OAR 411-030-0071.
(5) A single homecare worker is limited to 16
hours of awake care during a 24-hour work period.
(6) For the creation of a new service plan
(resulting from an assessment) beginning September 1, 2016, all homecare
workers are limited to 40 hours per week unless:
(a) The homecare worker's average paid
workweek hours in the months of March, April, and May 2016 equaled or exceeded
40 hours per workweek. These homecare workers are limited to no more than 50
hours per week.
(b) The individual
has received a "Weekly Cap" exception.
(7) In an emergency or unanticipated
situation where the homecare worker must provide critical care to ensure the
health or safety of the individual and the Department is unavailable to provide
prior-authorization, the following shall be permitted if the homecare worker or
individual notifies the Department within two business days of the date the
additional hours were first:
(a) Worked to
meet an ADL need totaling more than the hours established by section (5)(b) and
(c) of this rule.
(b) Worked to
meet an ADL need that exceed the total amount authorized by the Department on
the service plan authorization.
(c)
Totaling more than the hours established by section (5)(a) of this rule if an
unanticipated need arises that requires the homecare worker to remain awake to
provide necessary ADL care.
(8) 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. This section shall be
waived if the criteria in (6) are met.
(9) 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.
(10) 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.
(11) Payment by the
Department for Medicaid home and community-based services are only made for the
tasks described in this rule as ADL or IADL tasks. Services must be authorized
to meet the needs of an eligible individual and may not be provided to benefit
an entire household.
(12) An
individual who meets the Extended Waiver Eligibility criteria outlined in OAR
411-015-0030 is eligible to receive a maximum total of 10 hours per service
period to accomplish ADLs and IADLs.
Notes
Forms referenced are available from the agency.
Statutory/Other Authority: ORS 409.050, 410.070 & 410.090
Statutes/Other Implemented: ORS 410.010, 410.020 & 410.070
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