OAR 411-027-0020: Payment Limitations in Home and Community-Based Services

(1) PAYMENT FOR SERVICES. (a) Service payments under these rules are limited to services provided under Oregon's Medicaid State Plan K Option for individuals served through the Department’s Aging and People with Disabilities program area. (b) Home and community-based services include, but are not limited to: (A) In-home services (consumer-employed providers and contracted in-home care agencies). (B) Residential care facility services. (C) Assisted living facility services. (D) Adult foster home services. (E) Specialized living services. (F) Adult day services. (G) Home-delivered meals. (2) PAYMENT BASIS. (a) Unless otherwise specified, service payment is based upon an individual's assessed need for services as documented in CA/PS. (b) Payments for home and community-based services are not intended to replace the resources available to an individual from the individual's natural support system. The Department may authorize paid services only to the extent necessary to supplement potential or existing resources within an individual's natural supports system. (c) An individual with excess income must contribute to the cost of services pursuant to OAR 461-160-0610 and OAR 461-160-0620. (d) Service plans are based upon less costly means of providing adequate services consistent with consumer’s assessed need and choice. (e) An individual's progress is monitored by Department or AAA local office staff. When a change occurs in the individual's service needs that may warrant a change in the service payment rate, staff must update the service plan. (3) SERVICE PAYMENTS. All service payments must be prior authorized by the Department or AAA local office staff. (a) Department and AAA case managers authorize service payments from the rate schedule based on an individual's service program and assessed need for services documented in CA/PS. (b) Any rate that differs from the rate schedule must be pre-authorized by the Central Office. (4) RATE SCHEDULE. Services are paid at the rate in the Rate Schedule at the time of the service. The rate schedule must be updated: (a) When there is an increase in a rate on the schedule; or (b) Thirty (30) days prior to when any rate is reduced. (5) SPOUSAL SERVICES. The Department does not make direct payments to a spouse for providing community-based services except for in-home services as described in OAR chapter 411, division 030. (6) PAYMENTS FOR ADULT DAY SERVICES. (a) Payments to any Medicaid-contracted adult day services program, as described in OAR chapter 411, division 066, are authorized by Department or AAA local office staff and made in accordance with the rate schedule. (b) Adult day services may be authorized as part of an overall plan of services for service-eligible individuals and may be used in combination with other community-based services if adult day services are the appropriate resource to meet an identified need. (c) Department, or AAA local office staff, may authorize adult day services for payment as a single service or in combination with other home and community-based services. Adult day services are not authorized or paid for if another provider has been authorized payment for the same service. Payments authorized for adult day services are included in computing the total cost of services. (d) The Department pays for a half day of adult day services when four or less hours of services are provided, and pays for a full day of adult day services when more than four, but less than 24 hours are provided. (7) PAYMENT FOR HOME DELIVERED MEALS. (a) Payments to any Medicaid-contracted home delivered meals provider as described in OAR chapter 411, division 040 are authorized by Department or AAA local office staff and made in accordance with the rate schedule. (b) Medicaid home-delivered meals may be authorized as part of an overall plan of services for service-eligible individuals and may be used in combination with other in-home services if meals are the appropriate resource to meet an identified need. (8) PAYMENTS TO ASSISTED LIVING FACILITIES. Payments to any Medicaid-contracted assisted living facility (ALF) as defined in OAR 411-054-0005 are authorized by Department or AAA local office staff and made in accordance with the rate schedule. (a) The monthly service payment for an individual receiving services in an ALF is based on the individual's degree of impairment in each of the six activities of daily living as determined by CA/PS and the payment levels described in paragraph (c) of this subsection. The individual's initial service plan must be developed prior to admission to the ALF and must be revised if needed within 30 days. The individual's service plan must be reviewed and updated at least quarterly or more often as needed as described in OAR 411-054-0034. (b) Activities of daily living are weighted for purposes of determining the monthly service payment as follows: (A) Critical activities of daily living include elimination, eating, and cognition and behavior. (B) Less critical activities of daily living include mobility, bathing, personal hygiene, dressing and grooming. (C) Other essential factors considered are medical problems, structured living, medical management, and other needs. (c) Payment (Impairment) Levels. (A) Level 1 -- Service priority level 1-13 eligible individuals are qualified for Level 1 or greater. (B) Level 1 -- Service priority level 14-17, but would require institutionalization without supports within 30 days if authorized by Central Office. (C) Level 2 -- Individual requires assistance in cognition and elimination, mobility, or eating. (D) Level 3 -- Individual requires assistance in four to six activities of daily living or requires assistance in elimination, eating, and cognition. (E) Level 4 -- Individual is full assist in one or two activities of daily living or requires assistance in four to six activities of daily living plus assistance in cognition. (F) Level 5 -- Individual is full assist in three to six activities of daily living or full assist in cognition and one or two other activities of daily living. (d) The reimbursement rate for Department individuals receiving Medicaid services shall not be more than the rates charged by private paying individuals receiving the same type and quality of services.