justicedao/ipfs_state_laws huggingface dataset:
410-172-0730 Payment Limitations for Behavioral Health Services (1) Services shall be subject to periodic utilization review to determine medical appropriateness. (2) If a review reveals that a recipient received less than active treatment, payment may not be allowed under these rules and prior authorization may be cancelled. (3) The Division may make no payment for services if the Division or designee has determined the service is not medically appropriate. (4) Residential treatment services are provided to Medicaid Title XIX eligible individuals in facilities with 16 or fewer beds. Payment is excluded for individuals in “institutions of mental diseases” (IMD) who are over age 18 and under age 65. IMDs are defined in 42 CFR 435.1010. (5) For residential facilities, the Division shall pay for the day of admission but may not pay for the day of transfer or discharge. (6) Medicaid may not reimburse costs associated with room and board for recipients residing in Authority licensed residential treatment programs. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715 History: DMAP 26-2019, amend filed 06/26/2019, effective 06/28/2019 DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15 DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15
410-172-0760 Applied Behavior Analysis (1) Applied Behavior Analysis (ABA) services for the treatment of autism spectrum disorder shall be recommended by a licensed practitioner who has experience in the diagnosis and treatment of autism spectrum disorder and holds at least one of the following educational degrees and valid license: (a) Physician; (b) Psychologist; (c) Nurse practitioner specializing in developmental medicine, or; (d) Physician’s associate specializing in developmental medicine. (2) ABA services for the treatment of stereotyped movement disorder with self-injurious behavior due to neurodevelopmental disorder shall be recommended by a licensed practitioner, practicing within the scope of their license, who has experience or training in the diagnosis and treatment of stereotyped movement disorder with self-injurious behavior due to neurodevelopmental disorder. (3) Providers of ABA services eligible for direct payment shall hold the following license, registration, or declaration of practice: (a) Licensed Behavior Analyst as described in OAR 824-030-0010; (b) Licensed health care professional as defined in 2015 Oregon Laws Chapter 674, section 1 who is registered with the Oregon Behavior Analyst Certification Board as described in ORS 676.802(2)(a–h); (c) Individual holding a declaration of practice through the Oregon Behavior Analysis Regulatory Board as described in OAR 824-010-0005(10). (4) The following ABA service providers are not eligible for direct payment: (a) Assistant Behavior Analyst licensed by the Oregon Behavior Analysis Regulatory Board as described in OAR 824-030-0020; (b) Behavior Analysis Interventionists registered by the Oregon Behavior Analysis Regulatory Board as described in OAR 824-030-0040. (5) Initial and ongoing six month assessments of core skills by ABA licensed providers for the purpose of measuring progress achieved during ABA treatment must: (a) Use standardized, validated and reliable assessment tools that allow for tracking an individual’s progress over time; (b) Result in a treatment plan with specific, observable, and quantifiable goals that are relatable to identified skills deficits. (6) Initial and ongoing six month assessments of behavior that is considered to have an adverse impact on the individual’s development or is harmful to the individual or to others must have treatment goals that are specific, observable, and quantifiable and must relate to identified behavioral concerns. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715 History: DMAP 25-2025, minor correction filed 01/09/2025, effective 01/09/2025 DMAP 12-2017, f. & cert. ef. 4-4-17 DMAP 60-2016(Temp), f. & cert. ef. 10-7-16 thru 4-4-17 DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15 DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15
410-172-0790 Eligibility for Behavioral Health Personal Care Attendant Services (1) To be eligible for personal care services through the BH PCA program, an individual shall: (a) Demonstrate the need for assistance with personal care services from a qualified provider due to a disabling behavioral health condition and require medically appropriate services and meet the eligibility criteria described in this rule; (b) Be enrolled in the Medicaid OHP Plus benefit package. (2) An individual is not eligible to receive personal care services through the BH PCA program if: (a) The individual is receiving personal care services from a licensed 24-hour residential services program that includes but is not limited to a foster home, residential treatment home, or residential treatment facility; (b) The individual is in a prison, hospital, sub-acute care facility, nursing facility or other medical institution; (c) The individual’s assessed service needs are being met under other Medicaid-funded home and community-based service options of the individual’s choosing; (d) The individual's assessed service needs are met through the individual's natural support system as defined in these rules; or (e) The individual meets any criteria under excluded services and limitation as described in OAR 410-120-1200. (3) Behavioral health personal care attendant services are not intended to replace routine care commonly needed by an infant or child that is typically provided by the infant’s or child’s parent. (4) Behavioral health personal care attendant services may not be used to replace other non-Medicaid governmental services. (5) The Authority may close the eligibility and authorization for BH PCA services if an individual fails to: (a) Employ a qualified provider as described in OAR chapter 418 division 020; (b) Receive personal care from a qualified provider paid by the Authority for 30 continuous calendar days or longer. (6) Services through the BH PCA program shall not duplicate other Medicaid services. (7) To be eligible for personal care services through the BH PCA program, an assessment, service plan, any required prior authorization, and all Authority and DHS required forms must be current, complete, signed by a PCA Service Coordinator and placed in the individual medical record. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715 History: DMAP 38-2022, amend filed 03/23/2022, effective 03/23/2022 DMAP 36-2021, temporary amend filed 09/14/2021, effective 09/14/2021 through 03/12/2022 DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15 DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15
410-172-0796 Applying for State Plan Personal Care Services (1) Individuals of any age who are eligible for behavioral health personal care attendant (BH PCA) services as described OAR 410-172-0790(1) may apply through the Independent Qualified Agent (IQA) contracted with the Authority. Individuals applying for State Plan Personal Care (SPPC) services that are not eligible for, or are currently receiving services through the Division, may be referred to the Department's Office of Developmental Disabilities Services (ODDS) or Department's Office of Aging and People With Disabilities (APD). (2) An individual with an intellectual or developmental disability eligible for or receiving services through ODDS, a Community Developmental Disability Program (CDDP), or Support Services Brokerage may apply for State Plan personal care services through the local CDDP or the local support services brokerage. (3) An older adult or an adult with a disability eligible for, or receiving case management services from APD or Area Agency on Aging (AAA) may apply for SPPC services through the local APD or AAA office. (4) Individuals receiving benefits through the Department's Self-Sufficiency Programs (SSP) may apply for SPCC services through the local APD or AAA office. APD or the AAA is responsible for service assessment and for any planning and payment authorization for SPPC services if the applicant is determined eligible. (5) Children eligible for or receiving SPPC in a foster care setting shall apply through the Department’s Child Welfare program. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 413.042, 430.640, 414.025, 414.065, 430.705 & 430.715 History: DMAP 39-2022, adopt filed 03/24/2022, effective 03/24/2022
410-172-0850 Telemedicine for Behavioral Health (1) Telemedicine encompasses different types of programs, services, and delivery mechanisms for medically appropriate covered services within the recipient’s benefit package: (a) Patient consultations using telephone and online or electronic mail (e-mail) are covered when billed services comply with the practice guidelines set forth by the Health Evidence Review Commission and the applicable HERC-approved code requirements, delivered consistent with the HERC Evidence-Based Guidelines; (b) Patient consultations using videoconferencing, a synchronous (live two-way interactive) video transmission resulting in real time communication between a provider located in a distant site and the recipient being evaluated and located in an originating site, is covered when billed services comply with the billing requirements stated below. (2) Behavioral health services specifically identified as allowable for telephonic delivery are listed on the Behavioral Health Fee schedule published by the Authority. (3) Unless expressly authorized in OAR 410-120-1200 (Exclusions), other types of telecommunications are not covered such as images transmitted via facsimile machines and electronic mail when: (a) Those methods are not being used in lieu of videoconferencing, due to limited videoconferencing equipment access; or (b) Those methods and specific services are not specifically allowed pursuant to the Oregon Health Evidence Review Commission’s Prioritized List of Health Services and Evidence Based Guidelines. (4) Providers billing for covered telemedicine services shall: (a) Comply with HIPAA and the Authority’s Confidentiality and Privacy Rules and security protections for the patient in connection with the telemedicine communication and related records; (b) Obtain and maintain technology used in the telemedicine communication that is compliant with privacy and security standards in HIPAA and the Authority’s Privacy and Confidentiality Rules set forth in OAR 943 division 14; (c) Ensure policies and procedures are in place to prevent a breach in privacy or exposure of patient health information or records (whether oral or recorded in any form or medium) to unauthorized individuals; (d) Comply with the relevant HERC evidence-based guidelines for telephone and e-mail consultation. Refer to the current prioritized list and evidence based guidelines at http://www.oregon.gov/OHA/HPA/CSI-HERC/Pages/Prioritized-List.aspx ; (e) Maintain clinical and financial documentation related to telemedicine services as required in OAR 410-120-1360. (5) For purposes of behavioral health services, the Authority shall provide coverage for telemedicine services to the same extent that the services would be covered if they were provided in person. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715 History: DMAP 67-2018, minor correction filed 05/25/2018, effective 05/25/2018 DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15 DMAP 85-2014(Temp), f. 12-24-14, cert. ef. 1-1-15 thru 6-29-15
410-172-0860 Billing for Dual Eligible Individuals (1) As described in OAR 410-120-1280 (8), when an individual has both Medicare and coverage through Medicaid, providers shall make reasonable efforts to obtain payment from other resources including Medicare or other Third Party Liability (TPL). (2) In accordance with OAR 410-120-1280 (f), OAR 410-141-0420, and OAR 410-141-3420, behavioral health providers may bill the Division directly and may not be required to bill Medicare under the following circumstances: (a) For behavioral health services that are never covered by Medicare or another insurer; (b) For behavioral health services that are not covered when rendered by the following provider types: (A) Qualified Mental Health Professional (non-licensed) as defined in OAR 309-019-0105; (B) Qualified Mental Health Associate as defined in OAR 309-019-0105; (C) Professional Counselor or Marriage and Family Therapist licensed by the Oregon Board of Licensed Professional Counselors and Therapists; (D) Certified Peer Support Specialist as defined in OAR 950-060-0010; (E) Recovery Assistant; (F) Certified Alcohol and Drug Counselor. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 413.042, 414.025, 414.065, 430.640, 430.705 & 430.715 History: DMAP 106-2024, minor correction filed 06/11/2024, effective 06/11/2024 DMAP 32-2015, f. 6-24-15, cert. ef. 6-26-15
410-173-0000 Purpose (1) These rules ensure eligible Individuals served by the Oregon Health Authority (Authority), Health Systems Division (Division), have access to 1915(i) Home and Community Based State Plan Option services that are not defined in other rules in this chapter. These rules describe services intended to increase an Individual’s independence, empowerment, dignity, and human potential through the provision of person-centered and directed, flexible, efficient, appropriate, and cost-effective services. (2) Services described in these rules include: (a) Home and Community Based Services (HCBS); (b) Community Based Integrated Supports (CBIS); (c) Residential Habilitation; (d) Psychosocial Rehabilitation for Persons with Chronic Mental Illness (PSR); (e) Housing Support Services; (f) Home Delivered Meals. (3) Services described in this rule should improve eligible Individuals’ access to the greater community to the same degree as individuals who do not require services and supports to remain in their home or community; (4) Payments for the services outlined in these rules are limited to the lowest possible cost that meet the Individual's assessed needs. Payments are not intended to replace existing supports; (5) Medicaid is a payer of last resort. All other payment sources shall be billed prior to billing Medicaid for services. Statutory/Other Authority: ORS 409.050, 413.042, 413.085, 427.104 & 430.662 Statutes/Other Implemented: ORS 409.050, 413.042, 413.085, 427.007, 430.610, 430.620 & 430.662 – 430.670 History: DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024 DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019 DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019
410-173-0020 Functional Needs Assessment (1) The IQA shall meet face-to-face with Individuals or if applicable, their legal or authorized representative and in consultation with other persons identified by the individual to complete a Functional Needs Assessment to determine: (a) The Individual's abilities or need for assistance with IADLs and ADLs; (b) How the individual functioned during the thirty (30) days prior to the assessment date with consideration of how the person is likely to function in the thirty (30) days following the assessment date; and (c) The actual or predicted need for assistance from another person within the assessment time frame. (2) As part of the person-centered functional needs assessment process, the IQA uses a standardized assessment that includes: (a) The LOCUS; and (b) LSI. (3) Reassessments of functional needs are conducted face-to-face with the individual on the following schedule: (a) No less frequently than annually, prior to the annual 1915(i) program eligibility date, and no earlier than sixty (60) days prior to the expiration date of the current plan; or (b) When the individual or their legal representative, if applicable, requests reassessment; or (c) When the individual’s needs or circumstances have changed significantly. Statutory/Other Authority: ORS 409.050, 413.042, 413.085, 443.738, 427.104 & 430.662 Statutes/Other Implemented: ORS 409.050, 413.042, 413.085, 443.738, ORS 410.020, 427.007, 430.610, 430.620 & 430.622 – 430.670 History: DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024 DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019 DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019
410-173-0040 Individually Based Limitations (1) When certain HCBS setting qualities may not be met due to a threat to the health and safety of an Individual or others, a provider shall submit a request for an Individually-based limitation (IBL) to the IQA; (2) An IBL shall be supported by a specific assessed need and documented in the PCSP. The IQA shall complete a Division-approved form documenting the IBL. The form identifies and documents, at a minimum, the following requirements: (a) The specific and individualized assessed need justifying the IBL; (b) The positive interventions and supports used prior to any IBL; (c) Less intrusive methods that have been tried but did not work; (d) A clear description of the limitation that is directly proportionate to the specific assessed need; (e) Regular collection and review of data to measure the ongoing effectiveness of the IBL; (f) Established time limits for periodic reviews of the IBL to determine if the limitation shall be terminated or remains necessary; (g) The informed consent of the Individual or, as applicable, the legal representative of the individual, including any discrepancy between the wishes of the Individual and the consent of the legal representative, as evidenced by a signature and date; (h) An assurance that the interventions and support do not cause harm to the Individual; and (i) Documentation that the IBL shall be reviewed on a timeframe agreed upon by the PCS planning team at least every twelve (12) months. (3) Providers are responsible for: (a) Maintaining a copy of the completed and signed form documenting the consent to the appropriate limitation. The form shall be signed by the Individual, or, if applicable, the legal or authorized representative of the individual; (b) Regular collection and review of data to measure the ongoing effectiveness of and the continued need for the individually based limitation; and (c) Requesting a review of the individually- based limitation when a new individually-based limitation is indicated, or a change or removal of an individually based limitation is needed. Statutory/Other Authority: ORS 409.050, 413.042, 413.085, 443.738, ORS 430.021, 430.735, 426.072 & 443.739 Statutes/Other Implemented: ORS 409.050, 413.042, 413.085, 443.738, ORS 427.007, 430.610, 430.620 & 430.662 - 430.670 History: DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024 DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019 DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019
410-173-0045 Documentation Standards (1) Provider rendering HCBS are required to maintain records that fully support the extent of services for which payment is requested and provide the records to the Division or IQA upon request; (2) All records shall comply with documentation standards found in OAR 410-120-1360 and 410-172-0620 in addition to the following: (a) The name of the Individual receiving 1915(i) HCBS services; (b) The Medicaid Identification Number of the Individual receiving 1915(i) HCBS services; (c) The name of the provider offering 1915(i) HCBS services; (d) Type of service being provided as described in the PCSP including: (e) Date of service; (f) Start time of each service; and (g) End time of each service. (3) Providers shall document services and supports provided to the individual and how the services and supports relate to identified goals and objectives outlined in the PCSP; (4) Providers shall document the services and supports addressing the following HCBS qualities: (a) Employment and volunteer opportunities; (b) Individual choice of community activities and community access; (c) Access to and control of personal resources; and (d) Strategies identified in the PCSP to ensure the health and safety of the individual or others. (5) All Medicaid 1915(i) services provided in a person’s own, or family home must be captured using an Electronic Visit Verification (EVV) system to meet requirements in the 21st Century Cures Act. EVV systems shall electronically capture the following information at the time the service is occurring: (a) Type of service performed; (b) Individual receiving the service; (c) Date and location of the service; (d) Individual providing the service; and (e) Time the service begins and ends. (6) Information contained in the record shall be appropriate in quality and quantity to meet the professional standards applicable to the provider and any additional standards for documentation found in these rules, other Division rules, and pertinent contracts. Statutory/Other Authority: ORS 124.050 - 124.095, 163.275 & 443.765 Statutes/Other Implemented: ORS 124.050 - 124.095, 163.275 & 443.765 History: DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024 DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019 DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019
410-173-0055 Eligibility Criteria for Community Based Integrated Supports (1) To be eligible for CBIS defined in this rule, Individuals shall: (a) Be eligible for 1915(i) HCBS as outlined in OAR 410-173-0010 (b) Have identified needs for assistance with ADLs or IADLs requiring services and supports in the home and community that natural supports are unable to provide; and (2) Individuals determined eligible to receive CBIS shall be provided the choice of services and supports, who provides those services and supports, and where those services and supports are provided. The Individual’s choice shall be reflected by their signature, or, if appropriate, the legal or authorized representative’s signature of informed consent on the Individual’s PCSP. (3) These services cannot duplicate services received though other authorities. Statutory/Other Authority: ORS 413.042, 426.495, 430.610 & 430.630 Statutes/Other Implemented: ORS 413.042, 426.495, 430.610 & 430.630 History: DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024 DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019 DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019
410-173-0065 Eligibility Criteria for HCBS Residential Habilitation (1) To be eligible for HCBS Residential Habilitation Services defined in this rule, Individuals shall: (a) Be eligible for 1915(i) HCBS per OAR 410-173-0010; (b) Have assessed needs for HCBS Residential Habilitation Services requiring services and supports in the home and community that natural supports are unable to consistently provide; (c) Access one or more 1915(i) services at least one (1) time every thirty (30) days. (2) Individuals determined eligible to receive HCBS Residential Habilitation Services shall be provided the choice of services and supports, who provides those services and supports, and where those services and supports are provided. The Individual’s choice shall be reflected by their signature, or, if appropriate, the legally authorized representative, or authorized representative’s signature of informed consent; (3) These services cannot duplicate services received though other authorities. Statutory/Other Authority: ORS 413.042, 426.495, 430.630 & 430.640 Statutes/Other Implemented: ORS 413.042, 426.495, 430.630 & 430.640 History: DMAP 42-2024, amend filed 02/14/2024, effective 02/29/2024 DMAP 46-2019, adopt filed 11/07/2019, effective 11/26/2019 DMAP 12-2019, temporary adopt filed 05/21/2019, effective 06/01/2019 through 11/27/2019