Or. Admin. R. 410-173-0010 - Eligibility

Current through Register Vol. 60, No. 12, December 1, 2021

(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 an in-person face-to-face needs-based assessment by an external IQA who meets the requirements of a QMHP.
(3) To be eligible for services under the 1915(i) HCBS, documentation shall support that the individual meets the following requirements:
(a) Enrolled in Title XIX Medicaid;
(b) Twenty-one years of age or older;
(c) Diagnosed with a chronic mental illness as defined in ORS 426.495(1)(c)(B);
(d) Requires assistance in at least two instrumental activities of daily living (IADL) due to symptoms of a behavioral health condition; and
(e) Requires the provision of one or more 1915(i) services at least monthly.
(4) Eligibility reevaluation for 1915(i) HCBS shall be completed on the following schedule:
(a) At least every 12 months; and
(b) When an individual requests reevaluation; and
(c) When there is documented evidence indicating the Individual's circumstances or needs have changed significantly.
(5) 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 through a notice of planned action mailed within three business days after the 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.


Or. Admin. R. 410-173-0010
DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019

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

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