OAR 411-030-0050: Case Management

(1) ASSESSMENT. The assessment process identifies an individual's ability to perform ADLs, IADLs, and determines an individual's ability to address health and safety concerns. (a) The case manager must conduct an assessment in accordance with the standards of practices established by the Department in OAR 411-015-0008. (b) The assessment must be conducted by a case manager or other qualified Department or AAA representative with a standardized assessment tool approved by the Department in the home of the eligible individual, no less than annually. (2) PERSON-CENTERED SERVICE PLAN. (a) An individual receiving services, or the individual’s representative, and the individual's case manager, must consider in-home service options as well as assistive devices, architectural modifications, and other community-based resources to meet the service needs identified in the assessment process. (A) The individual or the individual's representative is responsible for choosing and assisting in developing less costly service alternatives, including the Consumer-Employed Provider Program and contracted in-home care agency services. (B) The case manager is responsible for -- (i) Determining eligibility for specific services; (ii) Presenting service options, resources, and alternatives to the individual to assist the individual in making informed choices and decisions; (iii) Identifying risks; (iv) Assisting the individual with developing backup plans; (v) Identifying the individual’s goals and preferences; (vi) Assessing the cost effectiveness of the individual's service plan; and (vii) Developing and coordinating a person-centered service plan. (C) The case manager must monitor the service plan and make adjustments as needed. (b) The Department takes necessary safeguards to protect an individual's health, safety, and welfare in implementing an individual's service plan in accordance with 42 CFR 441.302 and 42 CFR 441.570. When an individual with the ability to make an informed decision selects a service choice that jeopardizes health and safety, the Department or AAA staff shall offer or recommend options to the individual in order to minimize those risks. For the purpose of this rule, an "informed decision" means the individual understands the benefits, risks, and consequences of the service choice selected. Options that minimize risks may include offering or recommending: (A) Natural supports to help with safety or health emergencies; (B) An emergency response system; (C) A back-up plan for assistance with service needs; (D) Resources for emergency disaster planning; (E) A referral for long term care community nursing services; (F) Resources for provider and consumer training; (G) Assistive devices; or (H) Architectural modifications. (c) The Department or AAA may not authorize a service provider, service setting, or a combination of services selected by an eligible individual or the individual's representative when -- (A) The service setting has dangerous conditions that jeopardize the health or safety of the individual and necessary safeguards cannot be taken to improve the setting; (B) Services cannot be provided safely or adequately by the service provider based on -- (i) The extent of the individual's service needs; or (ii) The choices or preferences of the eligible individual or the individual's representative; (C) Dangerous conditions in the service setting jeopardize the health or safety of the service provider that is authorized and paid for by the Department, and necessary safeguards cannot be taken to minimize the dangers; or (D) The individual does not have the ability to make an informed decision, does not have a designated representative to make decisions on his or her behalf, and the Department or AAA cannot take necessary safeguards to protect the safety, health, and welfare of the individual. (d) The case manager must present the individual or the individual's representative with information on service alternatives and provide assistance to assess other choices when the service provider or service setting selected by the individual or the individual's representative is not authorized. (3) PAYMENT. (a) The service plan payment is considered full payment for Medicaid home and community-based services rendered. Under no circumstances is the service provider to demand or receive additional payment for these services from the consumer or any other source. (b) Additional payment to homecare workers or ICP employee providers for the same services covered by Medicaid in-home services or the Spousal Pay Program is prohibited. (c) For ICP, the service plan must include the service budget as described in OAR 411-030-0100. (d) For service plans in which a consumer lives in the relative homecare workers home, subsection (a) of this section does not apply to rent and living expenses.