OAR 410-172-0790: Temporary rule language in effect until 02/15/2027. Eligibility for State Plan Personal Care Program Services

(1) In order to be authorized by the Authority to receive State Plan Personal Care (SPCC) services, individuals must: (a) Apply for the SPPC program as outlined in OAR 410-172-0796; (b) Meet the initial eligibility criteria identified in section (2) of this rule; (c) Meet with the Authority’s designated IQA or the IQA’s Service Coordinator to administer a needs-based assessment outlined in OAR 410-172-0830; (d) Be able to demonstrate as determined through the needs-based assessment, the skills necessary to: (A) Have the knowledge, skills and capacity necessary for meeting the obligations of an employer of a personal care attendant (PCA) as outlined in OAR 410-172-0800; or (B) Having the knowledge, skills and capacity necessary for meeting the obligations of a co-employer of a direct support worker (DSW) as outlined in OAR 410-172-0845. (e) Participate in the development of a Person-Centered Service Plan led by the Authority’s designated IQA or the IQA’s Service Coordinator; and (f) Provide, when available and as reasonably requested by the Authority, the necessary information and documentation to assist the IQA in assessing the functional needs, including medical records and other provider documentation. (2) An individual of any age is eligible for personal care services through the SPPC program if they meet all of the other criteria as follows: (a) Be enrolled in a Medicaid OHP Plus benefit package; (b) Not be in foster care; (c) Demonstrates, through the Authority’s needs-based assessment the following: (A) The presence of mental health symptoms or a mental health condition; and (B) A medically necessary need for assistance with at least one ADL or IADL due to a functional limitation that, without assistance, would adversely affect the individual’s health, safety or welfare, as determined through the Authority’s needs based-assessment. (3) Subject to the individual meeting the criteria of sections (1) and (2) of this rule, the Authority will prior authorize the individual’s person-centered service plan (PCSP) before they can participate in the SPPC program. (4) An individual is not eligible to receive personal care services through the SPPC program and will not participate in a needs-based assessment 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 jail, prison, or other detention facility; hospital, sub-acute care facility; nursing facility; Institution for Mental Disease (IMD); Intermediate Care Facility for Individuals with Intellectual or Developmental Disabilities (ICF/IDD); 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 limitations as described in OAR 410-120-1200. (5) SPPC 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. (6) SPPC services must not be used to: (a) Replace or duplicate services available from other non-Medicaid governmental programs; or (b) Duplicate other Medicaid services. (7) The Authority may withdraw an individual’s eligibility determination or service authorization, or both, for SPPC services as outlined below in this rule: (a) An individual’s eligibility determination or service authorization may be withdrawn by the Authority if an individual fails to: (A) Employ a qualified provider either as a PCA as described in OAR chapter 418 division 020 or signs an agreement with the Agency with Choice to initiate services as described in OAR chapter 309 division 045 within 45 days of service authorization; or (B) Receive personal care from a qualified provider paid by the Authority at any time for a period of 30 continuous calendar days or longer. (b) If an individual’s eligibility determination or service authorization is withdrawn by the Authority, the Authority will provide the individual and as applicable, the individual’s Authorized Representative, a notice of action that complies with OAR 410-120-1865; or (c) If an individual’s eligibility determination or service authorization is withdrawn by the Authority, the individual has the right to be reauthorized for SPPC services, or reapply to the SPPC program, as set out in OARs 410-172-0774 through 410-172-0840.