OAR 410-173-0010: Eligibility

(1) Individuals who apply for state plan 1915(i) HCBS must be determined eligible for those services prior to receiving them. (a) For Individuals who are not enrolled in Title XIX Medicaid at the time they apply for 1915(i) HCBS shall have their eligibility for Title XIX Medicaid determined by The Oregon Department of Human Services (Department). The Department shall complete Title XIX Medicaid determinations according to the criteria set out in OAR chapter 461, divisions 135, 140, and 155. (A) If an individual is determined eligible for Title XIX Medicaid by the Department, they will participate in an assessment to determine eligibility for 1915(i) HCBS in accordance with section (2) of this rule. (B) If an individual is determined not eligible for Title XIX Medicaid by the Department, they will receive a decision notice in accordance with OAR chapter 461, division 175. (b) Individuals who are already enrolled in Title XIX Medicaid at the time they apply for 1915(i) HCBS, will participate in an assessment to determine eligibility for 1915(i) HCBS in accordance with section (2) of this rule. (2) Eligibility for 1915(i) HCBS is established by the Individual participating in a face-to-face administration of the functional needs assessment as defined in OAR 410-173-0005. The functional needs assessment is performed by the Authority’s Independent Qualified Agent (IQA) IQA who meets the requirements of a Qualified Mental Health Professional (QMHP) as defined in OAR 410-173-0005. (a) Telehealth or in-person meets the requirements for face-to-face and it is the Individuals choice to conduct the functional needs assessment in-person or via telehealth; (b) Individuals who are determined eligible for 1915(i) HCBS based on a functional needs assessment performed through the telehealth option must schedule an in-person follow up meeting with the IQA within ninety (90) days of the functional needs assessment; (c) Individuals who are determined not eligible for 1915(i) HCBS through an assessment performed in-person or through the telehealth option, shall receive a notice of ineligibility as set out in section (9) of this rule. (3) Prior to commencing the functional needs assessment, the IQA service coordinator shall provide the Individual and any legal guardian or Authorized Representative with information regarding service eligibility, any necessary referral processes, and services and supports covered under the 1915(i) HCBS State Plan Option or other Medicaid services the Individual may be eligible for. (a) Specifically, the IQA service coordinator shall provide education, instruction, and information about the following: (A) The needs assessment and the person-centered planning process, and how they are conducted; (B) The range and scope of Individual choices and options; (C) The process for changing the person-centered service plan; (D) The grievance and appeals process; (E) The Individual’s rights, including federal and state HCBS rights; (F) The risks and responsibilities of self-direction; (G) Free choice of providers and service delivery models; (H) Reassessment and review schedules; (I) Defining goals, needs and preferences; (J) Identifying and accessing services, supports and resources; (K) Development of risk management agreements; (L) Recognizing and reporting critical events, including abuse allegations; and (M) How to access and make reasonable accommodation requests. (b) The information above will be provided to the Individual and any legal guardian or Authorized Representative in accordance with section (4) below of this rule. (4) All education, instruction, and information regarding 1915(i) HCBS covered services, including eligibility, authorization, assessment, and service planning processes, as well as available providers, shall be provided in a manner that can be easily understood by the Individual and any legal guardian or authorized representative. Specifically, education, instruction, and information will be provided the Individual and any legal guardian or authorized representative in: (a) Their preferred language, including sign language; (b) Writing or orally, or both; and (c) Compliance with Section 1557 of the Affordable Care Act or the Americans with Disabilities Act, which includes the provision of auxiliary aids as needed. (5) To be eligible for services under the 1915(i) HCBS, the Individual must meet, and be documented in the Individual’s file by the IQA, all of the following requirements: (a) Be twenty-one (21) years of age or older; (b) Has a current diagnosis of a Serious Mental Illness as defined in OAR 410-173-0005; (c) The interRAI CMH determined that the Individual requires assistance in at least two (2) instrumental activities of daily living (IADL) due to symptoms of a mental health condition; and (d) Requires the provision of one (1) or more 1915(i) services at least monthly. (6) An Individual’s eligibility for 1915(i) HCBS shall be reevaluated by participating in a new functional needs assessment and updating of their PCSP, which shall be documented in the Individual’s file, in keeping with the schedule set out in OAR 410-173-0020. (7) Reassessment shall not be requested by any person or entity without consultation and consent of the Individual or the Individual’s legal representative or authorized representative. (8) Individuals are not eligible to receive 1915(i) HCBS when the Individual is receiving duplicate services as delivered through Medicare or other Medicaid programs, services, or other private insurance. The Individual may choose to receive services through either of those health care programs or private insurance, but they are prohibited from receiving duplicate services. (9) If it is determined the Individual is not eligible for 1915(i) HCBS based on the functional needs assessment or any other eligibility criteria set out in section (5) of this rule, the Individual and, if applicable, their legal representative or authorized representative, shall be notified by the Authority through a Notice of Action mailed within three (3) business days after completion of their functional needs assessment. All notifications shall: (a) Be sent through U.S. Postal Service (b) Include information about the Individual’s right to a contested case hearing through the Office of Administrative Hearings under the Oregon Administrative Procedures Act, ORS Chapter 183, and OAR 410-120-1860 through 410-120-1865; and (c) Include information about how to request a hearing, which may be made orally or in writing. If made in writing, the Individual may, but is not required to, use the form included in the notification.