justicedao/ipfs_state_laws huggingface dataset:
411-016-0020 Qualified Services Case Manager Services Case Managers (SCMs) must meet the following criteria: (1) Be employed by an Area Agency on Aging, the Department or a subcontractor of a Type B AAA transfer that was subcontracting to provide OPI case management prior to June 1, 2024. (2) Have completed the Department required training for case managers; and (3) The AAA or the Department has determined that the SCM has the skills, knowledge and ability for the SCM position and responsibilities. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.060, 410.070 & 414.065 History: APD 64-2024, adopt filed 11/20/2024, effective 11/22/2024 APD 22-2024, temporary adopt filed 05/20/2024, effective 05/31/2024 through 11/26/2024
411-016-0025 OPI-M Service Eligibility and Responsibilities of the Individual (1) For ongoing approval of an OPI-M service plan, the individual must receive case management services and the individual or their representative must participate in the person-centered service planning process to maintain OPI-M eligibility. (a) Individuals who do not have case management services or participate in the yearly person-centered service plan may have their OPI-M services end until the person-centered service plan is completed. (b) Individuals remain eligible for OPI-M until either the end of their continuous eligibility period or they voluntarily withdraw. (2) Individuals must participate in risk assessments and risk monitoring activities as a part of case management and service coordination. If individuals do not participate in the risk assessment and risk monitoring activities the case manager will continue to contact the individual at least once per month until services are added to the plan, the individual voluntarily withdraws or the end of the continuous eligibility period. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.060, 410.070 & 414.065 History: APD 64-2024, adopt filed 11/20/2024, effective 11/22/2024 APD 22-2024, temporary adopt filed 05/20/2024, effective 05/31/2024 through 11/26/2024
411-016-0040 Service Plan Hours (1) Through a person-centered planning process with the individual, the Services Case Manager (SCM) authorizes hours to address the individual’s unmet needs or to support the unpaid caregiver relationship. (2) A service plan may have no more than a maximum total of 40 hours of in-home services including both ADL and IADL hours, per pay period. (3) Hours are authorized to meet assessed ADL/IADL needs as defined in OAR 411-015-0006 and OAR 411-015-0007. (4) Hours should reflect only the minimum necessary for health and safety that supplement supports provided by natural supports and alternative service resources. The hours authorized must be documented in the service plan form. (5) For households with two or more eligible individuals receiving any combination of Medicaid funded or Oregon Project Independence in-home services, the service plan for each individual must avoid duplication of services. (6) Hours authorized for assessed needs are paid at the rates in accordance with OAR 411-027-0170 for In-Home Care Agencies and for Homecare Workers at rates published on the current rate schedule or the current collective bargaining agreement between the Department of Administrative Services on behalf of the State of Oregon and the Oregon Homecare Commission and Service Employees International Union, Local 503, Oregon Public Employees Union. (7) A provider may not receive payment from the Department for more than the total amount of in-home services hours authorized by the AAA or the Department on the service plan authorization form under any circumstances. All service payments must be prior authorized by a SCM or AAA or Department designated staff. (8) Payment by the Department for In-Home services hours are only made for the tasks described in OAR 411-015-0006 and OAR 411-015-0007 as ADL or IADL tasks. Services must be authorized to meet the needs of an eligible individual and may not be provided to benefit an entire household. (9) Respite hours may be authorized to replace an unpaid caregiver or natural supports providing ADL or IADL care who are temporarily unavailable to provide assistance. Respite hours must be included in the 40 in-home services hours limit. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.060, 410.070 & 414.065 History: APD 64-2024, adopt filed 11/20/2024, effective 11/22/2024 APD 22-2024, temporary adopt filed 05/20/2024, effective 05/31/2024 through 11/26/2024
411-016-0050 Limitations on In-Home Services Plans (1) The AAA or Department must take necessary safeguards to protect an individual’s health, safety, and welfare when implementing an individual’s service plan in accordance with 42 CFR 441.302 and 42 CFR 441.570. When an individual with the ability to make an informed decision selects a service choice that jeopardizes health and safety, AAA or Department staff shall offer or recommend options to the individual to minimize those risks. For this rule, an “informed decision” means the individual understands the benefits, risks, and consequences of the service choice selected. Minimizing risks may include offering or recommending one or more of the following: (a) Natural supports to help with safety or health emergencies; (b) An emergency response system; (c) A back-up plan for assistance with service needs; (d) Resources for emergency disaster planning; (e) A referral for long term care community nursing services; (f) Resources for provider and consumer training; (g) Assistive devices; or (h) Home modifications. (2) The Department or a AAA with the approval of the Department may decide not to authorize a service provider, a service or a combination of services selected by an eligible individual or the individual’s representative when: (a) There are dangerous conditions that jeopardize the health or safety of the individual and necessary safeguards cannot be taken to improve the situation; (b) Services cannot be provided safely or adequately by the service provider based on: (A) The extent of the individual’s service needs; or (B) The choices or preferences of the eligible individual or the individual’s representative; (c) Dangerous conditions jeopardize the health or safety of the service provider that is authorized and paid for by the Department, and necessary safeguards cannot be taken to minimize the dangers; or (d) The individual does not have the ability to make an informed decision, does not have a representative to make decisions on their behalf, and the AAA or Department cannot take necessary safeguards to protect the safety, health, and welfare of the individual. (3) The Services Case Manager (SCM) must present the individual or the individual’s representative with information on service alternatives and provide assistance to assess other choices when the service provider or service setting selected by the individual or the individual’s representative is not authorized. The SCM must document in the case file the service alternatives offered. (4) The service plan payment is payment in full for the Oregon Project Independence-Medicaid services. Under no circumstances, may any Medicaid-paid provider demand or receive additional payment from an eligible individual, or other entity on behalf of the individual, for any services in the OPI-M service plan. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.060, 410.070 & 414.065 History: APD 64-2024, adopt filed 11/20/2024, effective 11/22/2024 APD 22-2024, temporary adopt filed 05/20/2024, effective 05/31/2024 through 11/26/2024
411-016-0080 Homecare Workers and Provider Qualifications (1) For the purpose of this rule, case manager as used in OAR chapter 411, division 031 means the OPI-M Services Case Manager (SCM). (2) Homecare workers must be enrolled in and follow the rules in the Consumer-Employed Provider Program described in chapter 411, division 031 to provide in-home services as part of an OPI-M service plan. (3) A single homecare worker is limited to providing 16 hours of awake care during a 24-hour work period. (4) All homecare workers are limited to no more than 60 hours per week. (5) Homecare workers must use Electronic Visit Verification (EVV) as required in OAR 411-031-0040(10)(a). Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.060, 410.070 & 414.065 History: APD 64-2024, adopt filed 11/20/2024, effective 11/22/2024 APD 22-2024, temporary adopt filed 05/20/2024, effective 05/31/2024 through 11/26/2024
411-016-0090 In-Home Agency Services and Provider Enrollment (1) For the purpose of this rule, (a) Case manager as used in OAR 411-033-0020 is synonymous with the Services Case Manager in OAR 411-014-0010; and (b) Individual as used in OAR 411-033-0020 is modified to apply to people aged 60 or older or an adult aged 18 or older with physical disability. (2) In-Home Care Agency Services authorized as part of an OPI-M service plan must comply with OAR 411-033-0020 and with provider enrollment requirements and payment in OAR 411-033-0030. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.060, 410.070 & 414.065 History: APD 64-2024, adopt filed 11/20/2024, effective 11/22/2024 APD 22-2024, temporary adopt filed 05/20/2024, effective 05/31/2024 through 11/26/2024
411-016-0100 Adult Day Services (ADS) and ADS Provider Qualifications (1) An eligible individual may choose to receive services from an ADS. If an individual chooses to receive ADS services, their authorized hours will be reduced by the number of hours they are at the ADS provider. (2) If chosen by the eligible individual, the OPI-M Services Case Manager authorizes and monitors ADS services in an OPI-M service plan. The amount of time authorized for ADS should be used to reduce the number of hours authorized from the maximum in-home hours. (3) Adult Day Services programs must adhere to the standards in OAR 411-066-0020, registration requirements in OAR 411-066-0010 and be certified and maintain a Medicaid provider number as in OAR 411-066-0015. (4) Adult Day Services will be paid in accordance with OAR 411-027-0020(6). Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.060, 410.070 & 414.065 History: APD 64-2024, adopt filed 11/20/2024, effective 11/22/2024 APD 22-2024, temporary adopt filed 05/20/2024, effective 05/31/2024 through 11/26/2024
411-016-0110 Assistive Technology, Emergency Response Systems and Provider Qualifications (1) Assistive Technology such as electronic back-up systems and Emergency Response systems may be authorized in an OPI-M service plan by an OPI-M Services Case Manager for individuals who meet the criteria in OAR 411-035-0025. (2) Assistive Technology and Emergency Response systems must meet the criteria in OAR 411-035-0030. (3) Assistive Technology and Emergency Response System providers must meet the requirements of and provide services in compliance with OAR 411-035-0035. (4) All requests over $500 must be approved by designated Department Central Office staff. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.060, 410.070 & 414.065 History: APD 64-2024, adopt filed 11/20/2024, effective 11/22/2024 APD 22-2024, temporary adopt filed 05/20/2024, effective 05/31/2024 through 11/26/2024
411-016-0140 Chore Services and Provider Qualifications (1) Chore services assist individuals to maintain their health and safety and are beyond the scope of ADL and IADL tasks as defined in OAR 411-015-0006 and OAR 411-015-0007. (2) To be eligible for chore services, an individual must meet the criteria in OAR 411-035-0040. (3) Chore services must meet the eligible chore service criteria in OAR 411-035-0045. (4) Chore services are not subject to the 40-hour cap. (5) Chore services providers must meet the qualifications and follow the requirements in OAR 411-035-0050. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.060, 410.070 & 414.065 History: APD 64-2024, adopt filed 11/20/2024, effective 11/22/2024 APD 22-2024, temporary adopt filed 05/20/2024, effective 05/31/2024 through 11/26/2024
411-016-0150 Community Caregiver Supportive Services and Provider Qualifications (1) Community Caregiver Supportive Service may be authorized to assist the individual and their natural support systems. (2) Through a person-centered planning process with the individual, the Services Case Manager (SCM) must assess and document the need for Community Caregiver Supportive Services on the service plan form using the Unpaid Caregiver Assessment tool. (3) The caregiver meets the criteria for an unpaid caregiver in OAR 411-016-0130(1). (4) Services include but are not limited to: (a) Paid wellness services; (b) Group-based activities; (c) Peer supports; and (d) Facilitated support groups. (5) Community Caregiver Supportive Services providers must at a minimum meet the following requirements: (a) Be over age 18; (b) Have a high school diploma or GED; (c) Pass a department approved background check; (d) Have demonstrated experience in assisting caregivers of older adults and people with disabilities; (e) Are subject matter experts with demonstrated experience in their field; (f) Meet the training, licensing or credential requirements for the supportive service they are providing; and (g) Meet the qualifications to be a Medicaid enrolled provider and be enrolled as a Medicaid provider. (6) Services must be prior authorized by the SCM. (7) Providers are paid depending on the service by one of the following processes as directed by the Department: (a) Provider submits competitive rate bid for approval to the case manager; or (b) Invoice is submitted at the contracted rate. (8) No payment will be released to the provider until the work is finished and meets the specifications of the service. Statutory/Other Authority: ORS 410.020 & 410.070 Statutes/Other Implemented: ORS 410.020 & 410.070 History: APD 64-2024, adopt filed 11/20/2024, effective 11/22/2024 APD 22-2024, temporary adopt filed 05/20/2024, effective 05/31/2024 through 11/26/2024
411-016-0170 Home Delivered Meals and Provider Qualifications (1) To be eligible for home delivered meals a participant must: (a) Be eligible for OPI-M; (b) Be unable to complete meal preparation as defined in OAR 411-015-0007 on a regular basis without assistance; and (c) Not have natural supports available that are willing and able to provide meal preparation services. (2) Home Delivered Meals must meet the conflict-free case management expectations. When the only willing and qualified provider organization provides both case management and Home Delivered Meals, Department approved firewalls must be in place and followed to ensure a separation of functions within the organization. (3) Services Case Managers (SCMs) must perform all the functions of case managers authorizing Medicaid home delivered meals as described in OAR 411-040-0050. (4) If a participant is determined ineligible for Medicaid home delivered meals, but needs food assistance, the SCM shall refer the participant to the nearest Aging and Disability Resource Connection for assistance. (5) OPI-M Home Delivered Meals providers must meet: (a) The qualifications and responsibilities for Medicaid paid Home Delivered Meal providers in OAR 411-040-0030; and (b) The service requirements in OAR 411-040-0036, and (c) The staff and volunteer requirements in OAR 411-040-0037. (6) OPI-M paid meals must meet the requirements in OAR 411-040-0035. (7) The payment rate for Home Delivered Meals is documented in OAR 411-027-0170. (8) Home Delivered Meals must be prior authorized by the SCM. (9) Providers may be paid for no more than two meals per day per participant within the month. This service does not constitute the full nutritional regiment. (10) OPI-M home delivered meals may be authorized in combination with other in-home services if meals are an appropriate resource to meet an identified need. (11) If OPI-M home delivered meals are authorized, the service plan should be updated to address any duplicative meal preparation services. Statutory/Other Authority: ORS 410.070 & 411.070 Statutes/Other Implemented: ORS 410.060, 410.070, 410.240, 410.250, 410.270, 410.280 & 414.065 History: APD 64-2024, adopt filed 11/20/2024, effective 11/22/2024 APD 22-2024, temporary adopt filed 05/20/2024, effective 05/31/2024 through 11/26/2024
411-016-0180 Home Modifications and Provider Qualifications (1) Home modifications may be authorized for OPI-M eligible individuals whose circumstances meet the consumer environmental modifications criteria in OAR 411-035-0055. (2) Home modifications must be eligible environmental modifications described in OAR 411-035-0060. (a) An individual or the individual’s representative may request home modifications listed in OAR 411-035-0060 if needed to assist with the performance of an ADL or IADL, for the health and safety of the individual or to reduce the need for the assistance of a paid caregiver. (b) An individual or the individual’s representative must make requests to the Services Case Manager and provide any requested documentation of the unmet needs that will be addressed by the modification. (c) The Department will make all decisions on home modification exception requests. (3) Home modification providers must meet the environmental modifications provider qualifications and requirements in OAR 411-035-0065. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.060, 410.070 & 414.065 History: APD 64-2024, adopt filed 11/20/2024, effective 11/22/2024 APD 22-2024, temporary adopt filed 05/20/2024, effective 05/31/2024 through 11/26/2024
411-016-0190 Long Term Care Community Nursing Services and Provider Qualifications (1) Individuals with health-related needs as assessed by the Services Case Manager (SCM) are eligible for long term care community nursing services as described in Oregon Administrative Rule chapter 411, division 048. (2) For the purposes of these rules, the term case manager used in chapter 411, division 048 is synonymous with the term SCM used in these rules. (3) Long Term Care Community Nursing Services must be prior authorized by the SCM. (4) Limitations: (a) SCMs may not prior authorize long term care community nursing services that duplicate nursing services provided by Medicare or other Medicaid programs for which the individual is eligible. (b) Long term care community nursing services do not include: (A) Nursing activities used for other functions such as protective service investigations, pre-admission screenings, eligibility determinations, licensing inspections, case manager assessments, or corrective action activities. This limitation does not include authorized care coordination as defined in OAR 411-048-0160 (Definitions). (B) Reimbursement for direct hands-on nursing as defined in OAR 411-048-0160 (Definitions). (5) An exception to section (3)(b) of this rule may be requested as described in OAR 411-048-0250 (Exceptions). (6) Long Term Care Community Nursing Services providers must: (a) Provide the services and use the practices and procedures described in OAR 411-048-0180; and (b) Follow the Communication and Notification Practices in OAR 411-048-0190; and (c) Comply with the Additional Documentation requirements in OAR 411-048-0200; and (d) Meet the provider qualifications in OAR 411-048-0210; and (e) Meet orientation requirements in OAR 411-048-0240. (7) All billing and claims must comply with: (a) OAR 407-120-0330 (Billing Procedures) and 407-120-0340 (Claim and PHP Encounter Submission); and (b) OAR chapter 410, division 120 as applicable; and (c) The Long Term Care Community Nursing Procedure Codes and Payment Authorization Guidelines posted at https://www.oregon.gov/odhs/providers-partners/ltccn/Pages/resources.aspx#billing (8) Compensation for long term care community nursing services shall be defined in the Department’s rate schedule in OAR 411-027-0170 or through a contract with the Department. The Department may adjust rates in underserved areas to assure that individuals have access to long term care community nursing services. (9) The Department may grant exceptions as described in OAR 411-048-0250 to Long Term Care Community Nursing Services for OPI-M participants. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.060, 410.070 & 414.065 History: APD 64-2024, adopt filed 11/20/2024, effective 11/22/2024 APD 22-2024, temporary adopt filed 05/20/2024, effective 05/31/2024 through 11/26/2024
411-016-0200 Special Medical Equipment and Supplies (1) Individuals may be eligible for specialized or durable medical equipment and medical supplies if no other payer such as Medicare, Medicaid medical benefits or other insurance is paying for the equipment or supplies. (2) Special medical equipment or supplies must be necessary to support the consumer’s health or well-being. Special medical equipment is not assistive technology as defined in OAR 411-016-0005 and is not a replacement or substitute for caregiver or unpaid caregiver services. (3) Special medical equipment or supplies must be prior authorized in accordance with OAR 411-035-0015(2-6). (4) To be considered an eligible request, when possible, three bids are required from providers. Consumers should work with their Services Case Manager to obtain bids. Bids may not include comparative pricing done through the internet. (5) Special medical equipment or supplies must be approved by Central Office. (6) No monetary funds shall be released for installation of special medical equipment or supplies to the provider until the work is finished and is functioning as expected. (7) Upon delivery, providers must ensure: (a) The product is functioning correctly; (b) The product properly fits the consumer; and (c) If applicable, the individual is given adequate instruction on the product’s use. (8) Providers must supply a revised bid when requested by designated Central Office staff. (9) Providers must submit the final invoice for payment within one year of the date of service. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.020 & 410.070 History: APD 64-2024, adopt filed 11/20/2024, effective 11/22/2024 APD 22-2024, temporary adopt filed 05/20/2024, effective 05/31/2024 through 11/26/2024