Or. Admin. Code § 411-027-0025 - Payment for Residential Care Facility and Adult Foster Home Services
The Department reimburses for services provided to individuals residing in a residential care facility or an adult foster home according to the following:
(1) SERVICE PAYMENT.
The provider must agree to accept an amount determined pursuant to OAR
461-155-0270 for room and board
and a service payment determined by the Department pursuant to OAR
411-027-0020 or
411-027-0050 as payment in full
for all services rendered to an individual.
(2) SERVICE RATES. Service rates are based on
an individual's level of impairment and assessed need for services as
documented in CA/PS. Service eligibility levels are assigned based on the
degree of assistance an individual requires with activities of daily living and
certain procedures that must be performed by a provider.
(a) A base rate is paid for all individuals
in accordance with the rate schedule.
(b) Additional add-on payments are made for
individuals whose assessed needs meet add-on criteria. Add-on payments are paid
in accordance with the rate schedule.
(A) If
an individual is eligible for one add-on payment, an add-on payment is made in
addition to the base payment.
(B)
If an individual is eligible for two add-on payments, a total of two add-on
payments are made in addition to the base payment.
(C) If an individual is eligible for three
add-on payments, a total of three add-on payments are made in addition to the
base payment.
(D) An individual
that is eligible for Extended Waiver Eligibility, as defined and authorized in
OAR 411-015-0030 is not eligible for
an add-on payment.
(c)
Eligibility for add-on payments is made based on individual needs as documented
in CA/PS. An individual is eligible for an add-on payment if:
(A) The individual is full assist in mobility
or eating or elimination;
(B) The
individual demonstrates behavior that pose a risk to the individual or to
others and the provider must consistently intervene to supervise or redirect;
or
(C) The individual's medical
treatments, as selected and documented in CA/PS, require daily observation and
monitoring with oversight by a licensed healthcare professional, no less than
quarterly, and the facility has trained staff to provide such service and does
provide the service.
(3) PAYMENT RESPONSIBILITIES.
(a) An individual is entitled to retain a
personal allowance plus any income disregards pursuant to OAR
461-160-0620.
(b) An individual is responsible for payment
of the room and board amount pursuant to OAR
461-155-0270.
(A) An individual eligible for Medicaid under
OAR chapter 410, division 200 and eligible for long term care services under
OAR 411-015-0100 living in community
based care facilities may be eligible for room and board assistance if the
individual's gross income is less than the room and board amount defined in OAR
461-155-0270. The Department
issues a special needs payment to the facility, on the individual's behalf, for
the difference between the individual's income and the room and board
standard.
(B) An individual
eligible for Medicaid under OAR chapter 410, division 200 and receiving room
and board assistance must apply for all benefits for which the individual may
be eligible, per OAR 410-200-0220, to continue to
receive the room and board assistance. Individuals must follow all appeal
options if applicable.
(c) An individual must contribute any income
in excess of the personal allowance, income disregards, and room and board
payments to the provider toward the service payment pursuant to OAR
461-160-0610 and OAR
461-160-0620.
(d)The Department issues payment to the
provider for the difference between the service payment and the available
income of the individual.
(4) The provider may not charge the
individual, or a relative or representative of the individual, for items
included in the room and board or service payments for any items for which the
Department makes payment.
(5) The
Department is not responsible for damages to the provider's home, facility or
property, or obligations entered into with the individual.
Notes
Statutory/Other Authority: ORS 410.070
Statutes/Other Implemented: ORS 410.070
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