OAR 410-172-0830: Temporary rule language in effect until 02/15/2027. Service Assessment, Authorization and Reassessment

(1) The Authority is responsible for administering the State Plan Personal Care (SPPC) program and may contract with a designee, known as the Independent and Qualified Agent (IQA) and other qualified contracted parties, to fulfill some of the Authority’s administrative obligations with respect to assessment, authorization, and monitoring of SPPC services provided to individuals. (2) After an individual is referred and applies for SPPC services, the Authority is responsible for the following: (a) Receiving and processing requests for personal care services from any source; and (b) Designating a service coordinator who is a qualified mental health professional to conduct needs-based assessments of individuals using Authority approved tools to determine an eligible individual’s level of need for personal care services. (3) The tools used to perform needs-based assessments enable the service coordinator to: (a) Determine the ability of individuals to perform the ADL, IADL, and other personal care activities and tasks; and (b) Assess an individual’s service needs, identify the resources required to meet the individual’s needs and determine if the individual is eligible for other approved programs or other services. (4) Needs-based assessments are required to be performed when: (a) The initial request for personal care services is received; (b) At least every 12 months after the individual’s first needs-based assessment was performed if that first assessment resulted in an authorization of personal care services; (c) When requested by the individual or their authorized representative after they have been authorized and started receiving personal care services even if there has been less than 12 months since the last needs-based assessment was performed; and (d) When the individual’s circumstances or needs change. (5) When an individual is reassessed for service need (needs-based reassessment) as required under section (2) above of this rule, the Authority will designate a service coordinator to perform the reassessment. (a) The service coordinator must determine whether: (A) Individual meets all service eligibility criteria; (B) Individual’s person-centered service plan (PCSP), as described in OAR 410-172-0776, is cost effective; (C) Personal care services provided to the individual are medically necessary and appropriate; and (D) Personal care services provided meet the individual’s identified service needs. (b) If the individual remains eligible for the SPPC program the service coordinator must: (A) If needed, revise the PCSP as outlined in OAR 410-172-0776; (B) If needed, adjust the number of hours authorized, the types of personal care services included in the individual’s service plan, or both; (C) Document all personal care needs-based reassessment activities and tasks in individual’s medical record; and (D) Provide the individual’s approved tasks and hours to the designated OHA staff member to process for submission to the applicable EVV system. (6) Each individual who participates in a SPPC needs-based assessment and reassessment will be provided with a notice of action advising whether they have been approved for or denied SPPC services. (a) If the SPPC services are approved in full or in part, the notice will identify the scope, amount, and duration of the services approved. (b) If the SPPC services are denied in full or are approved but in an amount, scope, and duration that is less than requested, the individual’s notice, called a notice of adverse benefit determination (NOABD), will provide the individual with information regarding their right to a contested case hearing as outlined in OARs 410-120-1855, 410-120-1860, and 410-120-1865. (c) All notices will be provided to the individual within the timeframes outlined in OAR 410-120-1865. (d) Providers requesting the SPPC services on behalf of an individual will receive the same notice the individual receives as outlined in OARs 410-120-1860 and 410-120-1865. (7) The service coordinator shall meet with the individual when performing the needs-based assessment. The individual and the service coordinator may meet in person or using, telehealth technology. The individual has the right to choose whether to meet with the service coordinator in person or via telehealth. (a) An individual’s natural supports may attend, and if needed participate in, the needs-based assessment if requested by the individual or their authorized representative, if applicable; (b) An individual’s authorized representative may also attend, and if needed participate in, the needs-based assessment.