OAR 410-172-0840: Temporary rule language in effect until 02/15/2027. State Plan Personal Care Payment Limitations

(1) The number of personal care service hours authorized through the State Plan Personal Care (SPPC) program for an individual per 14-day service period is based on projected time needed to perform specific personal care services and is subject to the following: (a) Authorization of hours does not guarantee the personal care attendant (PCA) or the direct support worker (DSW) will work all authorized hours; (b) The total of these hours is limited to 270 hours per individual per service plan year unless an exception has been granted in writing by the Authority; and (c) PCA work hours are subject to limitations established in the applicable collective bargaining agreement. (2) The Authority will pay for medically necessary and appropriate SPPC services only when provider enrollment standards in OAR 410-120-1260, OAR chapter 418 division 020, and this rule are met, and both the individual and provider have been notified in writing that payment by the Authority is authorized. (3) The Authority shall make payment for personal care services through the approved program to the provider on an eligible individual’s behalf. Payment for services is not guaranteed. (a) To receive payment the provider must be an enrolled Provider as required by OAR 410-120-1260, meet all requirements of this rule and the Authority must verify that an individual’s provider meets the qualifications set forth in OAR chapter 418, division 020. (b) The Authority will only make payment to a provider for personal care services when those personal care services are fully documented as required by OAR 410-120-1360 and 410-172-0620, comply with all State and Federal EVV requirements, and Authority rules for Medicaid payment and recordkeeping OAR 410-120-1280, OAR 410-120-1340, and OAR 410-120-1360. (c) Only valid, complete and error-free claims are paid to providers. The PCA or DSW must use an Authority-approved EVV method to verify all personal care services. (d) The EVV and all personal care services records are subject to Authority pre-payment and post-payment review. The Authority will review billings, EVV, provider documentation, and other medical information for accuracy, medical appropriateness, level of service, correct coding, or for other reasons subsequent to payment of the claim. (e) Payment may be denied, adjusted, or recovered if errors or improper payment are identified by a pre-payment or post-payment review, consistent with OAR 410-120-1396 and OAR 410-120-1397. (4) Provider claims for payment must meet the following requirements: (a) In accordance with OAR 410-120-1300, all provider claims for payment must be submitted within 12 months of the date of service; (b) For SPPC delivered by a PCA the Authority will pay the standardized rate as described in the CBA in effect on the date of service; and (c) Providers must submit accurate and complete claims and adequately document services via a Authority approved EVV method and as required by OAR 410-120-1260 to receive payment from the Authority. (5) Payment may not be claimed until the hours authorized for the payment period have been completed. (6) Payments made to a provider are calculated to a single attendant and a single eligible individual as follows: (a) A PCA shall not bill or receive payment for two or more individuals at the same time on the same day of service; and (b) An Agency with Choice provider may not bill for overlapping services delivered by its DSWs. (7) Payments will not be made for personal care services during time periods when the individual is admitted to a hospital or facility. (8) Provider billing for personal care services must comply with Authority rules for Medicaid payment. Providers and the IQA must meet the following requirements to be considered valid: (a) The individual was eligible to receive Medicaid personal care services on the date of service; (b) The service billed was included in the individual’s approved service plan; (c) The services were provided and recorded using an Authority-approved EVV method; (d) The services were provided in a community setting and location approved in the individual’s service plan; and (e) The provider met all applicable enrollment, documentation and record-retention requirements, and program integrity obligations, such as disclosing and returning identified overpayments. (9) All payments to providers are subject to pre-payment and post-payment review as follows: (a) The Authority will review billings, EVV, work schedule records or other medical or financial information for accuracy, medical appropriateness, level of service, or for other reasons subsequent to payment of the claim; (b) Payment by the Authority does not restrict or limit the Authority or any state or federal oversight entity’s right to review or audit claims before or after the payment; (c) Claim payment may be denied or subject to recovery if medical review, audit, or other post-payment review determines the service was not provided in accordance with applicable rules or does not meet the criteria for quality of care or medical appropriateness of the care or payment; and (d) The Authority will conduct post-payment reviews as described in OAR 410-120-1396. (10) Providers and any entity billing the Authority on behalf of the provider, must submit true, accurate, and complete claims and encounters to the Authority. The Authority treats the submission of a claim or encounter, whether on paper or electronically, as certification of truth, accuracy and completeness. Providers that falsify or conceal a material fact in the submission of claims and encounters may be prosecuted under federal and state laws. (11) Providers must comply with OAR 410-120-1510, OAR 461-195-0601 and the requirements therein for prompt reporting of fraud, waste and abuse in the Medicaid program. Information on how to report may be found online at all times: https://www.oregon.gov/oha/FOD/PIAU/Pages/Report-Fraud.aspx (12) A person debarred, excluded, suspended, or terminated from participation in a federal or state medical program, such as Medicare or Medicaid, or whose license or certification to practice is suspended or revoked by a state licensing board shall not submit claims for payment in compliance with OAR 410-120-1380. (13) The Authority may suspend a SPPC provider and provider payments in the event it has determined there is suspected fraud or abuse as described in OAR 410-120-1500. Authority will suspend provider enrollment and any payments, in whole or in part, when a credible allegation of fraud exists pursuant to federal law under 42 CFR 455.23, whether presented to the Authority, Oregon Department of Human Services (ODHS), Department of Justice (DOJ), Medicaid Fraud Control Units (MFCU), or law enforcement entity; unless there is a pending investigation and good cause exists to continue payment.