reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0680 - Residential Treatment Services for Children

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Paid providers of children's psychiatric
			 residential treatment services shall:
(a)
			 Hold a Certificate of Approval Pursuant to OAR 309-012-0130  through
			 309-012-0220  from AMH; and
(b) Be
			 accredited as a psychiatric residential treatment facility for children under
			 age 18 by JCAHO, CARF, or any other accrediting organization with comparable
			 standards that is recognized by the State of Oregon;
(c) Be licensed by the Office of Licensing
			 and Regulatory Oversight (OLRO);
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0690 - Admission Procedure for Psychiatric Residential Treatment Services for Children

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Admission
			 procedures for children eligible for Medicaid shall be reviewed through an
			 independent psychiatric review process established by the Division to certify
			 the need for services.
(2) Referral
			 to psychiatric residential treatment services shall be because:
(a) Medically appropriate treatment of the
			 child's psychiatric condition requires services on a 24-hour residential basis
			 under the direction of a Licensed Medical Practitioner (LMP) as defined in OAR
			 309-019-0105; and
(b) The services
			 can reasonably be expected to improve the child's condition or prevent further
			 regression so that the services will no longer be needed.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0700 - 1915(i) Home and Community Based Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Habilitation services are designed to
			 help an individual attain or maintain their maximal level of independence,
			 including the individual's acceptance of a current residence and the prevention
			 of unnecessary changes in residence. Services are provided in order to assist
			 an individual to acquire, retain, or improve skills in one or more of the
			 following areas: Assistance with activities of daily living, cooking, home
			 maintenance, community inclusion and mobility, money management, shopping,
			 community survival skills, communication, self-help, socialization, and
			 adaptive skills necessary to reside successfully in home and community-based
			 settings.
(2) Psychosocial
			 rehabilitation services are medical or remedial services recommended by a
			 licensed physician or other licensed practitioner to reduce impairment to an
			 individual's functioning associated with the symptoms of a mental disorder or
			 to restore functioning to the highest degree possible.
(3) Providers seeking reimbursement for the
			 provision of rehabilitative behavioral health services shall meet one of the
			 following qualifications:
(a) Physician or
			 Physician Assistant licensed in the State of Oregon;
(b) Advanced Practice Nurse including
			 Clinical Nurse Specialist and Certified Nurse Practitioner licensed by the
			 Oregon Board of Nursing;
(c)
			 Psychologist licensed by the Oregon Board of Psychology;
(d) Professional Counselor or Marriage and
			 Family Therapist licensed by the Oregon Board of Licensed Professional
			 Counselors and Therapists;
(e)
			 Clinical Social Worker licensed by the Oregon Board of Licensed Social
			 Workers;
(f) Licensed Psychologist
			 Associate granted independent status as described in OAR
			 858-010-0039;
(g) Licensed Master
			 Social Worker licensed by the Oregon Board of Licensed Social Workers as
			 described in OAR 877-015-0105;
(h)
			 Licensed Occupational Therapist licensed by the Oregon Occupational Therapy
			 Licensing Board;
(i) Organizational
			 certificate of approval issued by the Division as described in OAR 309-012-0130  through 309-012-0220.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0710 - Residential Personal Care

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Personal
			 care services shall be provided to residents of Division licensed residential
			 treatment programs, as developmentally appropriate, as described in the
			 resident's person-centered service plan and residential plans of
			 care.
(2) Personal care services
			 are provided to individuals with behavioral health conditions that enable them
			 to accomplish tasks that they would normally do for themselves if they did not
			 have a behavioral health condition. Assistance may be in the form of hands-on
			 assistance for the resident, supervising, cueing, or redirecting so that the
			 individual performs the task on their own.
(3) Personal care services are provided in
			 accordance with an individual's assessment and the authorized plan for services
			 made by a provider meeting the qualifications of a Qualified Mental Health
			 Professional (QMHP) or Qualified Mental Health Associate (QMHA) as defined in
			 OAR chapter 309 division 019.
(4)
			 Personal care assistance relates to performance of activities of daily living
			 (ADLs) and instrumental activities of daily living (IADLs) as defined in these
			 rules.
(5) Personal care services
			 may be provided on a continuing basis or on episodic occasion.
(a) For residential personal care services
			 the Authority will pay the standardized rate in the behavioral health fee
			 schedule in effect on the date of service.
(b) Residential personal care service are
			 included in the per diem rate standardization described in OAR 410-172-0705.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0720 - Prior Authorization and Re-Authorization for Residential Treatment

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Authority
			 does not consider a request for a fixed episode of care or standardized length
			 of stay to be medically appropriate. Requested length of stay shall be based on
			 an assessment of individual need and the medical appropriateness of the
			 proposed time for treatment.
(2)
			 Residential treatment shall be outcome-based and provide service and supports
			 in a structured environment that allows the individual to successfully
			 reintegrate into an independent community-based living arrangement.
(3) Residential treatment is not intended to
			 be used as a long-term substitute for lack of available supportive living
			 environments in the community. Lack of appropriate and available supportive
			 community living environments shall be addressed and documented in transition
			 management and planning for the recipient.
(4) Authority-licensed residential treatment
			 programs are reimbursed for the provision of 1915(i) habilitative services as
			 described in OAR 410-173-0015, rehabilitative behavioral health services as
			 described in OAR 410-172-0660, substance use disorder services as described in
			 OAR 410-172-0670, or habilitation or personal care services as described in OAR
			 410-172-0705.
(5) The Division
			 shall authorize admission and continued stay in residential programs based on
			 the medical appropriateness of the request and supporting clinical
			 documentation.
(6) Prior
			 authorization requests for admission and continued stay shall be reviewed and
			 documented by the Authority or their contracted Independent and Qualified Agent
			 (IQA) to determine:
(a) The medical
			 appropriateness for residential services;
(b) The medical appropriateness of the
			 recommended length of stay;
(c) The
			 medical appropriateness of the recommended plan of care;
(d) The medical appropriateness of the
			 licensed setting; and
(e) The
			 current level of need.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0730 - Payment Limitations for Behavioral Health Services

Current through Register Vol. 63, No. 7, July 1, 2024
(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
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0740 - Repealed

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  413.042,
				  430.640
Stats. Implemented: ORS
				  413.042,
				  414.025,
				  414.065,
				  430.640,
				  430.705,
				  430.715
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0745

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042 & ORS
				  430.640
Statutes/Other Implemented: ORS
				  413.042 & ORS
				  430.640
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0750 - Repealed

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  413.042,
				  430.640
Stats. Implemented: ORS
				  413.042,
				  414.025,
				  414.065,
				  430.640,
				  430.705,
				  430.715
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0760 - Applied Behavior Analysis

Current through Register Vol. 63, No. 7, July 1, 2024
(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 assistant specializing in developmental medicine.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0780 - Behavioral Health Personal Care Attendant Program

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Behavioral Health Personal Care
			 Attendant (BH PCA) program ensures state plan personal care services support
			 and augment independence, empowerment, dignity and human potential through the
			 provision of flexible, efficient and suitable services to adults and children
			 eligible for State Plan personal care services. The BH PCA program is not
			 intended to supplement an individual's own personal abilities and resources,
			 including natural resources.
(2)
			 The BH PCA program provides essential personal care services that enable an
			 individual to move into or remain in their own home. Personal care services are
			 provided in accordance with an individual's authorized person-centered service
			 plan.
(a) Personal care services through the
			 BH PCA program are provided directly to an eligible individual and are not
			 meant to provide respite or other services to an individual's natural support
			 system. Personal care services may not be implemented for the purpose of
			 benefiting an individual's family members or the individual's
			 household;
(b) Personal care
			 services through the BH PCA program may not exceed 270 hours in a
			 person-centered service plan year from the date they were determined eligible
			 without an exception request approval from the Authority;
(c) When an individual's personal care
			 service needs are assessed as exceeding the annual maximum of 270 hours a year,
			 an exception request may be submitted in writing by the PCA Service Coordinator
			 and identify the following:
(A) The
			 exceptional personal care needs the individual is experiencing;
(B) The tasks that require hands on
			 assistance or direct supervision and cueing every time they occur;
			 and
(C) The date the additional
			 personal care services start and length of time to complete the
			 tasks.
(d) The Division
			 has up to 45 days upon receipt of an exception request to determine whether an
			 individual's assessed personal care needs warrant exceeding the 270-hour per
			 person-centered service plan year limitation and issue written notice to the
			 individual and the requesting provider;
(e) The PCA Service Coordinator will inform
			 the individual, through written notice, within 10 days of the Division's
			 decision including the individual's right to a hearing.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0790 - Eligibility for Behavioral Health Personal Care Attendant Services

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0796 - Applying for State Plan Personal Care Services

Current through Register Vol. 63, No. 7, July 1, 2024
(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
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0800 - Personal Care Attendant Employer-Employee Relationship

Current through Register Vol. 63, No. 7, July 1, 2024
(1) To be eligible for the BH PCA program,
			 the individual or the individual's consumer-employer representative shall
			 demonstrate the ability to perform the following consumer-employer
			 responsibilities:
(a) Locate, screen and hire
			 a qualified PCA provider;
(b)
			 Supervise and train a PCA provider;
(c) Schedule work hours, leave and
			 coverage;
(d) direct the PCA
			 provider in the provision of personal care services;
(e) Verify the authorized hours completed by
			 a PCA provider through an Authority approved electronic visit verification
			 (EVV) method if required;
(f)
			 Recognize, discuss, and attempt to correct any performance deficiencies with
			 the provider and provide appropriate, progressive disciplinary action as
			 needed;
(g) Discharge a provider
			 who does not perform PCA tasks in compliance with these rules; and
(h) Comply with all federal and state laws
			 related to employer responsibilities, including ensuring a safe work
			 environment.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0810

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  413.042,
				  430.640
Stats. Implemented: ORS
				  413.042,
				  414.025,
				  414.065,
				  430.640,
				  430.705,
				  430.715
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0830 - Personal Care Attendant Service Assessment, Authorization and Monitoring

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division
			 administers the personal care services program and may use a designee also
			 known as the Independent and Qualified Agent (IQA). The IQA is responsible for:
(a) Receiving and processing requests for
			 personal care attendant services from any source;
(b) Conducting a BH PCA assessments of
			 eligible individuals using Agency-provided assessment tools, prior to
			 initiating services through the BH PCA program and at least every 12 months
			 following initial authorization to determine program eligibility and level of
			 service need, and when the individual's circumstances or needs change. The IQA
			 shall comply with the following:
(A)
			 Assessment must be performed on all individuals by a PCA Service Coordinator
			 prior to receiving personal care services to determine their level of need.
			 Personal Care Services are available to all eligible individuals, including
			 children who are not in a foster care setting;
(B) In all following reassessments, the PCA
			 Service Coordinator shall review the individuals service eligibility, the cost
			 effectiveness of the individual's service plan, and whether the services
			 provided are medically appropriate and meeting the individual's identified
			 service needs;
(C) The PCA Service
			 Coordinator may adjust the number of hours authorized or the types of BH PCA
			 services included in the individual's service plan and shall authorize a new or
			 revised service plan based on the individual's current service needs. All
			 adjustments must be documented in individual's medical record and be authorized
			 in EVV system.
(c)
			 Facilitating the PCA enrollment process;
(d) Providing ongoing Service Coordination;
			 and
(e) Provide notice of action,
			 including:
(A) Notice of adverse benefit
			 determination (NOABD) with Medicaid contested case hearing rights to
			 individuals denied services through the BH PCA program in whole or in part;
			 or
(B) Notice of determination
			 describing increases in services hours based on assessed needs; and
(C) The NOABD must be provided to the
			 individual within the timeframes required by OAR 410-120-1865; and
(D) Notify the requesting provider in
			 accordance with OAR 410-120-1860  to 1865.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0840 - Personal Care Attendant Payment Limitations

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The number of personal care service hours
			 authorized through the BH PCA program for an individual per 14-day service
			 period is based on projected amounts of time to perform specific personal care
			 services to the eligible individual.
(a)
			 Authorization of hours does not guarantee hours or payment;
(b) The total of these hours is limited to
			 270 hours per individual per calendar year;
(c) The hour cap identified in the CBA;
			 and
(d) Individuals whose assessed
			 service needs exceed the 270-hour limit may receive approval from the Division
			 for additional hours.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0850 - Telemedicine for Behavioral Health

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0860 - Billing for Dual Eligible Individuals

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 173 - 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION › Section 410-173-0000 - Purpose

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 173 - 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION › Section 410-173-0010 - Eligibility

Current through Register Vol. 63, No. 7, July 1, 2024
(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 face-to-face needs-based
			 assessment by an external IQA who meets the requirements of a QMHP:
(a) Telehealth is considered face-to-face and
			 it is the Individuals choice to conduct the assessment in- person or via
			 telehealth;
(b) In-Person or
			 telehealth options are based on the choice and preference of the Individual
			 accessing HCBS;
(c) Individuals who
			 choose telehealth assessment options must schedule an in-person follow up
			 meeting within ninety (90) days of the functional needs assessment.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 173 - 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION › Section 410-173-0015 - Service Authorization

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Authorization medical appropriateness and medical necessity for Residential
			 Habilitation are satisfied by face-to-face eligibility or re-eligibility
			 assessments of 1915(i) HCBS State Plan Option. These services include:
(a) Completion of a Division approved
			 functional needs assessment tools; and
(b) Documentation of the accessed need for
			 services by the Individual in the person-centered service plan; and
(c) Agreed to in writing by the Individual,
			 legal representative or authorized representative, providers, Case Management
			 Entity (CME) and IQA PCSP Coordinator.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 173 - 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION › Section 410-173-0020 - Functional Needs Assessment

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 173 - 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION › Section 410-173-0030 - Qualifications for Home and Community Based Services Providers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Providers of
			 1915(i) HCBS shall meet the following qualifications for each type of service
			 they are providing as described in this rule and:
(a) Meet all necessary provider
			 qualifications, including relevant experience, as outlined in: OAR chapter 309,
			 division 019; chapter 309, division 035, division 040, OAR chapter 410,
			 division 172; and OAR chapter 950, division 060; and
(b) Be enrolled by the Division as a Medicaid
			 provider as outlined in OAR 410-120-1260.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 173 - 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION › Section 410-173-0035 - Home and Community Based Services and Setting Qualities

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Residential and
			 non-residential HCBS settings shall support Individuals in having the same
			 opportunities for integration, access, choice, and rights as Individuals not
			 accessing 1915(i) HCBS;
(2)
			 Providers of 1915(i) HCBS shall develop, implement, and maintain policies and
			 procedures to address the following HCBS residential and non-residential
			 setting requirements;
(a) The setting is
			 integrated in and supports the same degree of access to the greater community
			 as people not receiving HCBS, including opportunities for Individuals enrolled
			 in or receiving HCBS to:
(A) Seek employment
			 and work in competitive integrated employment settings;
(B) Engage in greater community
			 life;
(C) Control personal
			 resources; and
(D) Receive services
			 in the greater community.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 173 - 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION › Section 410-173-0040 - Individually Based Limitations

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 173 - 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION › Section 410-173-0045 - Documentation Standards

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 173 - 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION › Section 410-173-0050 - HCBS Community Based Integrated Supports

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Community-Based Integrated Supports
			 (CBIS) are services and supports offered to Individuals that require assistance
			 in the acquisition, retention, or improvement with life management,
			 socialization skills and community engagement and community integration and
			 engagement to maintain their maximum level of functioning and integration
			 within the broader community, to the same degree as Individuals who do not
			 access Medicaid 1915(i) CBIS. These services are provided face-to-face as
			 chosen by the Individual and as described and approved in the Individual's PCSP
			 and include:
(a) Supervision, support,
			 training, and assistance necessary for an individual to develop, maintain or
			 improve skills and competencies necessary to function as independently as
			 possible in the following areas:
(A)
			 Independent living skills
(B)
			 Behavior management skills;
(C)
			 Self-Advocacy skills;
(D) Financial
			 literacy;
(E) Social
			 skills;
(F) Communication
			 skills;
(G) Therapeutic activities;
			 and
(H) Community integration,
			 access and inclusion.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 173 - 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION › Section 410-173-0055 - Eligibility Criteria for Community Based Integrated Supports

Current through Register Vol. 63, No. 7, July 1, 2024
(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
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 173 - 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION › Section 410-173-0060 - HCBS Residential Habilitation

Current through Register Vol. 63, No. 7, July 1, 2024
(1) HCBS Residential Habilitation Services
			 are designed to assist and support an Individual to maintain, reacquire, or
			 improve skills and functioning in ADL and IADL due to the symptoms of a
			 behavioral health condition;
(2)
			 HCBS Residential Habilitation shall include supervision, support, training, and
			 assistance necessary for an Individual to develop, maintain or improve skills
			 and competencies necessary to function as independently as possible and to the
			 same degree as Individuals who do not access 1915(i) HCBS in the following
			 areas:
(a) Behavior management
			 skills;
(b) Financial
			 literacy;
(c) Social
			 Skills;
(d) Communication
			 skills;
(e) Therapeutic
			 activities;
(f) Community
			 integration access, and inclusion; and
(g) Community navigation skills.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 173 - 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION › Section 410-173-0065 - Eligibility Criteria for HCBS Residential Habilitation

Current through Register Vol. 63, No. 7, July 1, 2024
(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.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 173 - 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION › Section 410-173-0070 - HCBS Psychosocial Rehabilitation for Persons with Chronic Mental Illness

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Psychosocial
			 Rehabilitation (PSR) services shall be identified and agreed upon within the
			 PCSP and shall:
(a) Support the desires and
			 goals of the Individual receiving services;
(b) Increase the independence of the
			 Individual receiving PSR;
(c)
			 Reduce an Individual's need for assistance from another person; and
(d) Maintain the health and safety of the
			 Individual and others in the home or community.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 173 - 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION › Section 410-173-0075 - Eligibility Criteria for HCBS Psychosocial Rehabilitation for Persons with Chronic Mental Illness

Current through Register Vol. 63, No. 7, July 1, 2024
(1) To be
			 eligible for PSR services outlined in these rules, Individuals shall:
(a) Be eligible for 1915(i) HCBS as outlined
			 in OAR 410-173-0010  and
(b) Have
			 assessed needs for PSR requiring services and supports in the home and
			 community;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 173 - 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION › Section 410-173-0085 - Eligibility for Housing Support Services

Current through Register Vol. 63, No. 7, July 1, 2024
(1) To be eligible for Housing Support
			 Services outlined in these rules, Individuals shall:
(a) Be eligible for 1915(i) Housing Support
			 Services be outlined in these rules or OAR 410-173-0010;
(b) Have assessed needs for Housing Support
			 Services as approved and documented in the PCSP;
(c) Not have other resources to provide the
			 same housing support services identified in the PSCP
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 173 - 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION › Section 410-173-0090 - Home Delivered Meals

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 1915(i) home delivered meals shall be provided to eligible Individuals who are
			 home bound, live in their own home, and are unable to complete meal
			 preparation, to assist an Individual to remain in their own home and are
			 intended to provide one (1) meal per day;
(2) Home delivered meal services shall be
			 provided in the following settings, as identified, and approved within the
			 PCSP:
(a) Community; or
(b) Individuals own or family home.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 173 - 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION › Section 410-173-0095 - Eligibility for Home Delivered Meals

Current through Register Vol. 63, No. 7, July 1, 2024
(1) To be eligible for 1915(i) home delivered
			 meals and Individual must:
(a) Be 1915(i)
			 HCBS as outlined in OAR 410-173-0010  eligible;
(b) Have assessed needs for Home Delivered
			 Meals as documented and approved in the PCSP;
(c) Be homebound and live in their own
			 home;
(d) Not have natural supports
			 available that are willing and able to provide meal preparation
			 services;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 173 - 1915(i) HOME AND COMMUNITY BASED SERVICES STATE PLAN OPTION › Section 410-173-0100 - Provider Qualifications for Home Delivered Meals

Current through Register Vol. 63, No. 7, July 1, 2024
(1) To be in alignment with the provision of
			 services, home delivered meal providers must have contracts with, or be, an
			 Area Agency on Aging or AAA as defined in 411-002-0100(1).
(2) The provider must be in compliance,
			 during all stages of food service operation, with applicable federal, state,
			 and local regulations, codes, and licensure requirements relating to fire,
			 health, sanitation, safety, building and other provisions relating to the
			 public health, safety, and welfare of meal patrons.
(3) The provider must demonstrate that menu
			 standards are developed to sustain and improve a participant's health through
			 the provision of safe and nutritious meals that are approved by a
			 dietician.
(4) Each provider must
			 be an enrolled Medicaid provider approved to provide Medicaid home delivered
			 meals.
(5) The provider must ensure
			 that all requirements in OAR 411-040-0035  through 411-040-0037  are
			 met.
(6) Providers must ensure that
			 anyone who delivers meals:
(a) Have passed a
			 background check as defined in OAR 407-007-0275; or
(b) Uses an approved carrier.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 180 - RENUMBERED › Section 410-180-0300 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042,
				  414.635  & 414.665
Statutes/Other Implemented: ORS
				  414.635  & 414.665
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 180 - RENUMBERED › Section 410-180-0305 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042, ORS
				  414.635  & 414.665
Statutes/Other Implemented: ORS
				  414.635,
				  414.665  & 181.537
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 180 - RENUMBERED › Section 410-180-0310 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042,
				  414.635  & 414.665
Statutes/Other Implemented: ORS
				  414.635  & 414.665
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 180 - RENUMBERED › Section 410-180-0312 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042,
				  414.635  & 414.665
Statutes/Other Implemented: ORS
				  414.635  & 414.665
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 180 - RENUMBERED › Section 410-180-0315 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042, ORS
				  414.635  & 414.665
Statutes/Other Implemented: ORS
				  414.635,
				  414.665  & 181.537
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 180 - RENUMBERED › Section 410-180-0320 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042, ORS
				  414.635 & 414.665
Statutes/Other Implemented: ORS
				  414.635,
				  414.665 &
				  181.537
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 180 - RENUMBERED › Section 410-180-0325 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042, ORS
				  414.635  & 414.665
Statutes/Other Implemented: ORS
				  414.635,
				  414.665  & 181.537
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 180 - RENUMBERED › Section 410-180-0326 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042, ORS
				  414.635  & 414.665
Statutes/Other Implemented: ORS
				  414.635,
				  414.665  & 181.537
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 180 - RENUMBERED › Section 410-180-0327 - Repealed

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  413.042,
				  414.635 &
				  414.665
Stats. Implemented: ORS
				  414.635 &
				  414.665
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 180 - RENUMBERED › Section 410-180-0340 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042, ORS
				  414.635  & 414.665
Statutes/Other Implemented: ORS
				  414.635,
				  414.665  & 181.537
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 180 - RENUMBERED › Section 410-180-0345 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042,
				  414.635  & 414.665
Statutes/Other Implemented: ORS
				  414.635  & 414.665
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 180 - RENUMBERED › Section 410-180-0350 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042,
				  414.635  & 414.665
Statutes/Other Implemented: 414.635, 414.665 &
				  181.537
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 180 - RENUMBERED › Section 410-180-0355 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042,
				  414.635  & 414.665
Statutes/Other Implemented: ORS
				  414.635  & 414.665
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 180 - RENUMBERED › Section 410-180-0360 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Statutory/Other Authority: ORS
				  413.042,
				  414.635  & 414.665
Statutes/Other Implemented: ORS
				  414.635  & 414.665