Or. Admin. Code § 410-173-0010 - Eligibility

(1) Individuals applying to receive state plan 1915(i) HCBS shall be determined by the Department of Human Services (Department) to meet Title XIX Medicaid eligibility criteria. The Department shall complete Title XIX Medicaid eligibility determinations according to OAR chapter 461, division 135, division 140, and division 155. Individuals denied eligibility to Title XIX shall receive a basic decision notice from the Department in accordance with OAR 461-175;

(2) Eligibility for 1915(i) HCBS is established through a diagnostic and face-to-face needs-based assessment by an external IQA who meets the requirements of a QMHP:

(a) Telehealth is considered face-to-face and it is the Individuals choice to conduct the assessment in- person or via telehealth;

(b) In-Person or telehealth options are based on the choice and preference of the Individual accessing HCBS;

(c) Individuals who choose telehealth assessment options must schedule an in-person follow up meeting within ninety (90) days of the functional needs assessment.

(3) During the initial interaction or engagement with the Individual, the IQA case manager provides information to the Individual, or those people chosen by the Individual regarding service eligibility, any necessary referral processes, and services and supports covered under the 1915(i) HCBS State Plan Option or other eligible Medicaid services. The IQA case manager shall provide education, instruction, and information about the following:

(a) The needs assessment and the person-centered planning process, and how they are conducted;

(b) The range and scope of Individual choices and options;

(c) The process for changing the person-centered service plan;

(d) The grievance and appeals process;

(e) The Individual's rights, including federal and state HCBS rights;

(f) The risks and responsibilities of self-direction;

(g) Free choice of providers and service delivery models;

(h) Reassessment and review schedules;

(i) Defining goals, needs and preferences;

(j) Identifying and accessing services, supports and resources;

(k) Development of risk management agreements; and

(l) Recognizing and reporting critical events, including abuse allegations;

(m) How to access and make reasonable accommodation requests.

(4) Education, instruction, and information are provided orally and in writing in a manner and language easily understood by the individual and others the Individual has chosen to participate in the person-centered assessment and planning process. The IQA has developed print and online information about home and community-based services and supports, including information about available providers, services and the processes to referral and access to HCBS covered services and providers.

(5) To be eligible for services under the 1915(i) HCBS, documentation shall support that the Individual meets the following requirements:

(a) Twenty-one (21) years of age or older;

(b) Diagnosed with a chronic mental illness as defined in ORS 426.495(1)(c)(B) or a Severe and Persistent Mental Illness, other than those caused by substance use;

(c) Requires assistance in at least two (2) instrumental activities of daily living (IADL) due to symptoms of a behavioral health condition; and

(d) Requires the provision of one (1) or more 1915(i) services at least every thirty (30) days.

(6) Eligibility reevaluation for 1915(i) HCBS shall be completed on the following schedule:

(a) At least every twelve (12) months; and

(b) When an Individual requests a reassessment; or

(c) When there is documented evidence indicating the Individual's circumstances or needs have changed significantly.

(7) Reassessment shall not be requested by any person or entity without consultation and consent of the Individual or the Individual's legal representative or authorized representative.

(8) Individuals are not eligible to receive 1915(i) HCBS when the Individual is receiving duplicate services as delivered through Medicare or other Medicaid programs, services, or other private insurance. The Individual may choose to receive services through any authority but may not receive duplicate services.

(9) If it is determined the Individual is not eligible for 1915(i) HCBS based on the needs-based criteria, the Individual and their legal representative or authorized representative, if applicable, shall be notified by the Authority through a Notice of planned Action mailed within three (3) business days after completion of their functional needs assessment. Notification to the recipient shall provide a hearing request form and notice of hearing rights explaining the right to a contested case hearing through the Office of Administrative Hearings under the Oregon Administrative Procedures Act, ORS Chapter 183, and the rules adopted thereunder.

Notes

Or. Admin. Code § 410-173-0010

DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019; DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019; DMAP 42-2024, amend filed 02/14/2024, effective 2/29/2024

Statutory/Other Authority: ORS 409.050, 413.042, 413.085, 413.085, 414.025, 414.070, 427.104 & 430.662

Statutes/Other Implemented: ORS 409.050, 413.042, 413.085, 413.085, 414.025, 414.070, 427.007, 430.610, 430.620 & 430.662 - 430.670