Or. Admin. Code § 411-033-0030 - Medicaid In-Home Care Agency Provider Enrollment, Requirements, and Payment

(1) PROVIDER ENROLLMENT.

(a) Application and Agreement. A provider must be an enrolled Medicaid provider in order to be eligible to receive payment from the Department for claims in connection with services provided by an IHCA.

(b) The criteria for provider enrollment includes, but is not limited to:

(A) Meeting all program-specific requirements;

(B) Providing a copy of the IHCA agency's current OHA Public Health issued comprehensive classified license;

(C) Obtaining a Medicaid Provider Number;

(D) Current Business registration and assumed business name (DBA), if applicable, with the Oregon Secretary of State's Corporations Division; and

(E) Completing a Medicaid Provider Enrollment Agreement.

(2) Staffing Requirements. According to OAR 333-536-0070, the agency owner or administrator shall ensure the agency has qualified and trained employees sufficient in number to meet the needs of the clients receiving services 365 days per year, including holidays.

(3) On-site Monitoring and Assessment.

(a) The IHCA shall provide to the Department or the AAA a quarterly summary report for each Medicaid individual, which includes documentation of client needs and services delivered. These records must be maintained by the IHCA to provide the records necessary to fully disclose the extent of the services, care, and supplies furnished to beneficiaries.

(b) The IHCA shall provide a copy of all information and documents as requested by the Department or the AAA. This requested information may include, but is not limited to:

(A) Individual records (OAR 333-536-0085).

(B) Individual nursing services (OAR 333-536-0080).

(C) Quality improvement records (OAR 333-536-0090).

(D) Complaint investigation findings (OAR 333-536-0043).

(E) Organization, administration, and personnel records (OAR 333-536-0050).

(F) Individual surveys of services and payments (OAR 333-536-0041).

(G) The requested information shall be submitted to the Department or the AAA within five business days of the request. However, if the Department or AAA office indicates the request involves individual safety, well-being, or a protective service investigation, the information must be submitted within 24 hours of the request.

(c) The IHCA shall cooperate with any quality assurance visits regarding monitoring of any provision of IHCA services required by the Department.

(d) The IHCA shall participate in individual conferences with the Department or AAA case managers, as requested.

(4) Insurance Requirements. Insurance requirements are defined in the Provider Enrollment Agreement.

(5) Payment and Financial Reporting.

(a) The case manager shall authorize reimbursement for the service hours identified in the individual's Medicaid Management Information System (MMIS) plan of care.

(b) The IHCA shall comply with section 12006(a) of the 21st Century Cures Act using an electronic visit verification system that will verify, at the time of service, with respects to visits conducted as part of personal care services, the following:

(A) The type of service performed;

(B) The individual receiving the service;

(C) The date of the service;

(D) The location of the service delivery;

(E) The individual providing the service; and

(F) The time the service begins and ends.

(c) The IHCA must provide the department with a monthly report showing:

(A) The consumer(s) name.

(B) The consumer(s) Medicaid prime number.

(C) The date service(s) were provided.

(D) The location service(s) were provided.

(E) The start and end time of service(s) provided.

(F) The service(s) provided.

(G) An attestation that all claims submitted met EVV requirements.

(d) The IHCA must use MMIS to submit claims for reimbursement of Medicaid authorized services. All claims must be submitted no later than 12 months from date of service.

(e) The IHCA shall be reimbursed --

(A) Only for services delivered to an individual.

(B) Only at the approved hourly rate for ADL and IADL services.

(C) For up to three hours at the ADL care rate, for the required, completed initial assessment.

(D) For community transportation mileage related to an assessed ADL or IADL need (e.g., shopping). Reimbursement for community transportation may not include mileage for an employee commuting to and from the individual's home. The IHCA employee must maintain valid driver's license, current vehicle registration and necessary auto insurance, if transporting the Medicaid individual. Proof must be available upon the request of the Department.

(f) IHCAs shall be reimbursed per the rates established in the rate schedule for home and community-based services in OAR 411-027-0170.

Notes

Or. Admin. Code § 411-033-0030

APD 12-2017, f. & cert. ef. 5/30/2017; APD 17-2023, temporary amend filed 10/11/2023, effective 11/1/2023 through 4/28/2024; APD 9-2024, amend filed 03/25/2024, effective 3/28/2024

Statutory/Other Authority: ORS 409.050, 410.070, 410.090 & 413.085

Statutes/Other Implemented: ORS 410.010, 410.020, 410.070 & 413.085