Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0705 - Residential Rate Standardization

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 The following terms and acronyms have the described meanings when appearing in
			 OAR 410-172-0705:
(a) "Acuity" means the
			 level of residential service and support needs of an individual experiencing
			 functional deficits resulting from the symptoms of a diagnosed mental health
			 condition or complicating medical, behavioral, or cognitive
			 conditions.
(b) "Active Engagement"
			 means service hours provided to individuals in a residential treatment program
			 that support personal care and other habilitative services. Active engagement
			 hours:
(A) May include providing habilitation
			 services to an individual or small groups;
(B) May occur before, during, or after the
			 provision of ADL and IADL services for an individual;
(C) May include offsite activities with
			 program staff;
(D) May not include
			 Psychosocial Rehabilitative Services (PRS).
(c) "Activities of Daily Living (ADL)" means
			 those personal, functional activities required by an individual for continued
			 well-being, health, or safety. Examples of ADL include eating,
			 dressing/grooming, bathing/personal hygiene, mobility (ambulation and
			 transfer), elimination (toileting, bowel, and bladder management), and
			 cognition/behavior;
(d) "Community
			 Mental Health Program (CMHP)" means the organization of all services for
			 individuals with mental or emotional disorders operated by, or contractually
			 affiliated with, a local Mental Health Authority operated in a specific
			 geographic area of the state under an intergovernmental agreement or direct
			 contract with the Authority. CMHPs are operated pursuant to OAR chapter 309,
			 division 014;
(e) "CMS" means
			 Centers for Medicare and Medicaid Services, the federal agency that administers
			 Medicaid;
(f) "De Minimis
			 Threshold" means the Office of Management and Budget (OMB) threshold of 10
			 percent for government program-related administrative costs;
(g) "Direct Care" means active engagement and
			 supervision care for individuals in a residential treatment program;
(h) "Division" or "Health Systems Division"
			 means the Oregon Health Authority, Health Systems Division and its employees
			 and authorized agents that is the organizational unit responsible for
			 administration of state and federally-funded medical assistance programs
			 including Title XIX Medicaid and Title XXI State Children's Health Insurance
			 Program (SCHIP);
(i) "General
			 Ledger" means the main accounting record of a company or
			 organization;
(j) "Habilitation" or
			 "Habilitative Services" means services designed to help an individual attain or
			 maintain their maximal level of independence and includes, but is not limited
			 to, services provided in order to help an individual acquire, retain, or
			 improve skills in ADLs and IADLs, community survival skills, communication,
			 self-help, socialization, and adaptive skills necessary to reside successfully
			 in an individual's home or a community-based setting;
(k) "Home and Community Based Services
			 (HCBS)" means services and supports that assist eligible individuals to remain
			 in their home and community in accordance with the Code of Federal Regulations
			 and Oregon Administrative Rules;
(l) "Independent and Qualified Agent (IQA)"
			 means Oregon's contracted vendor to perform functional needs assessments,
			 person-centered service planning service coordination, transition coordination,
			 service authorizations, and utilization review and management for individuals
			 requesting or receiving 1915(i) Home and Community-Based Services, other
			 Medicaid-funded behavioral health services, or state General Fund behavioral
			 health services in an individual's home or a community-based setting. The IQA
			 conducts initial and annual 1915(i) HCBS State Plan Amendment eligibility
			 determinations and redeterminations;
(m) "Instrumental Activities of Daily Living
			 (IADL)" means those self-management activities performed by an individual on a
			 day-to-day basis but are not essential to basic self-care and independent
			 living. Examples of IADLs include but are not limited to housekeeping, laundry,
			 shopping, transportation, medication management and meal preparation;
(n) "Level of Service Inventory
			 (LSI)" means a person-centered assessment of the residential service and
			 support needs of an individual experiencing functional deficits resulting from
			 the symptoms of a diagnosed mental health condition;
(o) "Minimum Wage Regions" means geographic
			 areas within Oregon in which fixed minimum hourly wage rates are set lower than
			 the minimum wage rate as authorized by ORS
			 653.025;
(p) "Per Diem" means a payment made for each
			 day an approved service is provided;
(q) "Performing Provider" means the direct
			 care staff member actually providing a service to an individual in a
			 residential treatment program or separately billing a rehabilitative service to
			 an individual residing in a residential treatment program;
(r) "Person-Centered Service Plan (PCSP)"
			 means the written description of the supports, desired outcomes, activities,
			 and resources required for an individual to achieve and maintain personal
			 goals, health, and safety as described in OAR 411-004-0030  and developed in
			 compliance with OAR 309-035-0185  through 0190. The PCSP must be completed and
			 signed prior to the individual receiving HCBS;
(s) "Personal Care" means assistance with the
			 performance of ADLs and IADLs;
(t)
			 "Program Capacity" means the number of beds licensed for residential treatment
			 in a location;
(u) "Provider" means
			 an individual, organizational provider, or CMHP that is enrolled by the
			 Division to provide personal care, other habilitative services, or
			 PSR;
(v) "Psychosocial
			 Rehabilitation Services (PSR)" means 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;
(w) "Related Organization" means an entity
			 that is under common ownership or control with, has control of, or is
			 controlled by another organization. An entity is related if it has:
(A) Five percent or more ownership interest
			 in the other organization; or
(B)
			 Capacity derived from any financial or other relationship, whether exercised,
			 to directly or indirectly influence or direct the activities of the other
			 organization.
(x)
			 "Residential Treatment Facility (RTF)" has the meaning provided in ORS
			 443.400(11)
			 subject to exclusions as provided in ORS
			 443.405;
(y) "Residential Treatment Home
			 (RTH)" has the meaning provided in ORS
			 443.400(12)
			 subject to exclusions as provided in ORS
			 443.405;
(z) "Resident" means an individual receiving
			 treatment in a residential treatment program;
(aa) "Residential Services Costs" means costs
			 associated with the provision of mental health services to individuals in
			 residential treatment programs. Costs include direct and indirect services
			 required to meet an individual's assessed needs for personal care and other
			 habilitative services. Residential services costs do not include costs related
			 to providing psychosocial rehabilitation services (PSR);
(bb) "Residential Treatment Program" means a
			 RTF, RTH, SRTF, and YAT facility that is licensed to provide mental health
			 services but does not include adult foster homes as defined in OAR
			 309-040-0305;
(cc) "Retainer
			 Payment" means a payment made for medical, behavioral, or psychiatric related
			 temporary absences of 30 days or less from residential treatment programs for
			 which the Division has provided prior authorization;
(dd) "Secure Residential Treatment Facility
			 (SRTF)" has the meaning provided by OAR 309-035-0105(60);
(ee) "Standardized Rate" means a tiered
			 payment rate for personal care and other habilitative services in a residential
			 treatment program based on individual acuity, program capacity, and minimum
			 wage regions;
(ff) "Start-Up Costs"
			 means one-time costs incurred prior to the first resident being admitted;
(gg) "Supervision Hours" means the
			 staff hours in a mental health residential treatment program for overseeing
			 patients' general activities throughout the day;
(hh) "Young Adult in Transition Facility
			 (YAT)" means a facility when that facility is providing services to an
			 individual who is developmentally transitioning into independence as defined in
			 OAR 309-019-0105  and is of an age not less than 17 years and six months, and
			 not more than 25 years.