Or. Admin. Code § 411-375-0040 - Fiscal and Accountability Responsibility

(1) DIRECT SERVICE PAYMENTS. The Department, case management entity, or contracted fiscal intermediary makes payment to an independent provider on behalf of an individual for all services.

(a) Payment is considered full payment for the services rendered. The independent provider may not, under any circumstances, demand or receive additional payment for Department-funded services from the individual or any other source.

(b) The Department only makes payment for services authorized in an ISP, included in a Service Agreement, and delivered by a provider authorized in eXPRS to deliver the service.

(c) The Department does not make Department funds available to an individual or common law employer to pay an independent provider.

(d) The Department only makes payment to an enrolled provider who actually performs the authorized services. Federal regulations prohibit the Department from making payment to a collection agency.

(e) All Department funds paid to a personal support worker must come through a fiscal intermediary.

(f) Department funds may only be paid to a personal support worker who has properly completed all Department required paperwork for fiscal intermediary payments.

(2) TIMELY SUBMISSION OF CLAIMS. In accordance with 42 CFR 447.45, all claims for services must be submitted within 12 months from the date of services in order to be considered for payment. A claim submitted after 12 months from the date of services may not be considered for payment.

(3) CLAIM OR ENCOUNTER SUBMISSION.

(a) Submission of a claim, encounter, or other payment request document constitutes the agreement of an independent provider to all of the following:

(A) The services were delivered in compliance with the Service Agreement in effect on the date of service.

(B) The information on the claim, encounter, or other payment request document, regardless of the format, is true, accurate, and complete.

(C) The independent provider understands payment of the claim, encounter, or other payment request document is from Department funds and any falsification or concealment of a material fact may result in prosecution under federal and state laws.

(b) The independent provider must submit a claim for payment directly into eXPRS, unless an exception has been granted by the case management entity.

(A) Claims for payment submitted by independent providers who are not personal support workers must include documentation from the provider of services delivered.

(B) Claims for payment submitted by personal support workers must meet the requirements of a properly completed timesheet as defined by the Collective Bargaining Agreement including submission of progress notes as required by OAR 411-375-0035.

(c) A personal support worker must record hours worked using the Electronic Visit Verification interface for eXPRS, unless an exception has been granted by the Department or case management entity. All determinations regarding exceptions to recording hours worked using Electronic Visit Verification are final and only effective through the end date of the date on the approved exception.

(4) CLAIM OR ENCOUNTER AUTHORIZATION. Authorization of a submitted claim, encounter, or other payment request document by the employer, constitutes agreement the independent provider delivered services in accordance with the claim.

(5) PAYMENT LIMITATIONS.

(a) Department funds may not pay for services delivered by an independent provider who does not possess an active provider number issued by the Department on the date services are delivered.

(b) An active provider number with the Department is not a guarantee that an independent provider shall receive any minimum amount of work or payment from the case management entity.

(c) Payment is not made for services delivered to any individual prior to the following:

(A) The return of a signed Service Agreement, specific to the individual, to the case manager of the individual.

(i) When the provider is a personal support worker, a completed Service Agreement must include a dated signature from the common law employer and the personal support worker.

(ii) When the provider is an independent provider, but not a personal support worker, a completed Service Agreement must include the name and dated signature of the individual or as applicable their legal or designated representative.

(B) Authorization of the services in eXPRS.

(d) A personal support worker may not work more than 40 hours in a workweek, inclusive of travel time and time worked with other Department programs, as a personal support worker or homecare worker unless the personal support worker meets the criteria in subsection (A) or (B) of this section.

(A) A personal support worker may work 50 hours per workweek, inclusive of travel time and time worked with other Department programs, if the personal support worker was paid for more than an average of 40 hours per workweek during the months of March, April, and May of 2016.

(B) A personal support worker may work more than 40 hours in a workweek if an exception has been granted by the case management entity or the Department. All determinations regarding exceptions to the limitation on workweek hours are final.

(6) ANCILLARY CONTRIBUTIONS FOR PERSONAL SUPPORT WORKERS.

(a) FICA. The case management entity or contracted fiscal intermediary applies applicable FICA regulations on behalf of the individual, including the following:

(A) Withholding the FICA contribution of the personal support worker from the payment to the personal support worker.

(B) Submitting the FICA contribution of the individual and the amounts withheld from the payment to the personal support worker to the Social Security Administration.

(b) BENEFIT FUND ASSESSMENT. The Workers' Benefit Fund pays for programs that provide direct benefits to an injured worker and the beneficiary of the injured worker and also assists an employer in helping an injured worker return to work. The Department of Consumer and Business Services sets the Workers' Benefit Fund assessment rate for each calendar year. The case management entity or contracted fiscal intermediary calculates the hours rounded up to the nearest whole hour and deducts an amount rounded up to the nearest cent. The case management entity or contracted fiscal intermediary performs the following duties on behalf of the individual:

(A) Deducts the share of the Benefit Fund assessment rate for the personal support worker for each hour or partial hour worked.

(B) Collects the share of the Benefit Fund assessment rate for the individual for each hour or partial hour of paid services received.

(C) Submits the contributions of the personal support worker and the individual to the Workers' Benefit Fund.

(c) The case management entity or contracted fiscal intermediary submits the unemployment tax.

(7) STATE AND FEDERAL INCOME TAX WITHHOLDING.

(a) The case management entity or contracted fiscal intermediary withholds state and federal income taxes on all payments to personal support workers, as indicated in the Collective Bargaining Agreement.

(b) Personal support workers must complete and return all applicable Internal Revenue Service (IRS) forms.

(A) Personal support workers working with individuals receiving services through a CDDP, Brokerage, or CIIS must return all applicable fiscal intermediary forms to the fiscal intermediary for the Department.

(B) The fiscal intermediary must apply standard income tax withholding practices in accordance with 26 CFR 31.

Notes

Or. Admin. Code § 411-375-0040

APD 30-2014(Temp), f. & cert. ef. 7-1-14 thru 12-28-14; APD 48-2014, f. 12-26-14, cert. ef. 12/28/2014; APD 29-2016, f. & cert. ef. 6/29/2016; APD 33-2016(Temp), f. 8-30-16, cert. ef. 9-1-16 thru 2-27-17; APD 4-2017, f. 2-21-17, cert. ef. 2/28/2017; APD 38-2019, amend filed 10/29/2019, effective 11/1/2019

Statutory/Other Authority: ORS 409.050

Statutes/Other Implemented: ORS 410.600, 410.606-619 & 427.007