OAR 411-030-0070: Maximum Hours of Service

(1) LEVELS OF ASSISTANCE FOR DETERMINING SERVICE PLAN HOURS. (a) "Minimal Assistance" means an individual is able to perform the majority of an activity but requires some assistance from another person. (b) "Substantial Assistance" means an individual is able to perform only a small portion of the tasks that comprise an activity without assistance from another person. (c) "Full Assistance" means an individual needs assistance from another person through all tasks of an activity every time the activity is attempted. (2) MAXIMUM SERVICE PERIOD HOURS FOR ADL. (a) The planning process uses the following maximum hours limitations for each service period for ADL tasks. Maximum hours in each assistance level are not guaranteed. Hours authorized must be based on the service needs of an individual as determined by the Case Manager during the person-centered service planning process. (b) For in-home benefit plans created after May 21, 2018, the following maximums apply: (A) Eating: (i) Minimal assistance, three hours. (ii) Substantial assistance, nine hours. (iii) Full assistance, fourteen hours. (B) Dressing and Grooming: (i) Minimal assistance, two hours. (ii) Substantial assistance, seven hours. (iii) Full assistance, nine hours. (C) Bathing and Personal Hygiene: (i) Minimal assistance, five hours. (ii) Substantial assistance, seven hours. (iii) Full assistance, twelve hours. (D) Mobility: (i) Minimal assistance, five hours. (ii) Substantial assistance, seven hours. (iii) Full assistance, twelve hours. (E) Elimination (Toileting, Bowel, and Bladder): (i) Minimal assistance, five hours. (ii) Substantial assistance, nine hours. (iii) Full assistance, fourteen hours. (F) Cognition: (i) Minimal assistance, three hours. (ii) Substantial assistance, six hours. (iii) Full assistance, twelve hours. (c) Service plan hours for ADL may only be authorized for an individual if the individual requires assistance (minimal, substantial, or full assist) from another person in the tasks associated with the activity of daily living as determined by a service assessment applying the parameters in OAR 411-015-0006. (d) The Case Manager may authorize fewer hours than the maximum number of hours in any or all ADL tasks based on their assessment of the individual’s unmet need. The Case Manager must document the reason for authorizing fewer hours than the maximum number of hours allowed. The case manager may authorize fewer hours than the maximum for any of the following defined reasons: (A) Reduced frequency or duration of an ADL need. (B) Durable medical equipment or home modification reduces need for assistance. (C) Individual preference. (D) Natural supports. (E) Provided or funded by another agency. (e) For households with two or more eligible individuals, each individual's ADL service needs must be considered separately. (f) Hours authorized for ADL are paid at the rates in accordance with the rate schedule. The Independent Choices Program cash benefit is based on the hours authorized for ADLs paid at the rates in accordance with the rate schedule. Participants of the Independent Choices Program may determine their own employee provider pay rates but must follow all applicable wage and hour rules and regulations. (3) MAXIMUM SERVICE PERIOD HOURS FOR IADL. (a) The planning process uses the following limitations for time allotments for IADL tasks. Maximum hours in each assistance level are not guaranteed. Hours authorized must be based on the unmet service needs of an individual as determined by the case manager during the person-centered service planning process. (A) Medication Management: (i) Minimal assistance, one hour. (ii) Substantial assistance, two hours. (iii) Full assistance, five hours. (B) Transportation: (i) Minimal assistance, one hour. (ii) Substantial assistance, one hour. (iii) Full assistance, two hours. (C) Meal Preparation: (i) Minimal assistance: (I) Breakfast, one hour. (II) Lunch, one hour. (III) Supper, two hours. (ii) Substantial assistance: (I) Breakfast, two hours. (II) Lunch, two hours. (III) Supper, three hours. (iii) Full assistance: (I) Breakfast, five hours. (II) Lunch, five hours. (III) Supper, six hours. (D) Shopping: (i) Minimal assistance, one hour. (ii) Substantial assistance, two hours. (iii) Full assistance, three hours. (E) Housekeeping and Laundry: (i) Minimal assistance, two hours. (ii) Substantial assistance, five hours. (iii) Full assistance, nine hours. (b) Hours authorized for IADL are paid at the rates in accordance with the rate schedule. The Independent Choices Program cash benefit is based on the hours authorized for IADLs paid at the rates in accordance with the rate schedule. Participants of the Independent Choices Program may determine their own employee provider pay rates but must follow all applicable wage and hour rules and regulations. (c) When two or more individuals eligible for IADL task hours live in the same household, the assessed need in medication management and transportation must be authorized separately. Payment is made for the individual with the highest of the allotments in meal preparation, shopping, and housekeeping and laundry and a total of two additional IADL hours per service period for each additional individual to allow for the specific IADL needs of the other individuals. (d) Service plan hours for IADL tasks may only be authorized for an individual if the individual requires assistance (minimal, substantial, or full assist) from another person in that IADL task as determined by a service assessment applying the parameters in OAR 411-015-0007. Hours authorized must incorporate the frequency and the duration of the tasks within each instrumental activity of daily living. For housekeeping, the size of the home may be used to reduce the hours. For meal preparation, hours must be reduced if an individual is receiving Medicaid home delivered meals. (e) The Case Manager may authorize fewer hours than the maximum number hours in any or all IADLs based on their assessment of the individual's unmet need. The Case Manager must document the reason for authorizing fewer hours than the maximum hours. The Case Manager may reduce hours for any of the following reasons: (A) Reduced frequency or duration of an IADL need. (B) Durable medical equipment or home modification reduces need for assistance. (C) Individual preference. (D) Natural supports. (E) Provided by or funded by another agency. (F) Small living space. (4) When one or more eligible individuals are living in the same household and receiving in-home services, the total number of hours authorized for ADLs and IADLs may not exceed 24 hours within any 24-hour period in the same household unless an exception is granted as described in OAR 411-030-0071. (5) A single homecare worker is limited to 16 hours of awake care during a 24-hour work period. (6) For the creation of a new service plan (resulting from an assessment) beginning September 1, 2016, all homecare workers are limited to 40 hours per week unless: (a) The homecare worker’s average paid workweek hours in the months of March, April, and May 2016 equaled or exceeded 40 hours per workweek. These homecare workers are limited to no more than 50 hours per week. (b) The individual has received a “Weekly Cap” exception. (7) In an emergency or unanticipated situation where the homecare worker must provide critical care to ensure the health or safety of the individual and the Department is unavailable to provide prior-authorization, the following shall be permitted if the homecare worker or individual notifies the Department within two business days of the date the additional hours were first: (a) Worked to meet an ADL need totaling more than the hours established by section (5)(b) and (c) of this rule. (b) Worked to meet an ADL need that exceed the total amount authorized by the Department on the service plan authorization. (c) Totaling more than the hours established by section (5)(a) of this rule if an unanticipated need arises that requires the homecare worker to remain awake to provide necessary ADL care. (8) A provider may not receive payment from the Department for more than the total amount authorized by the Department on the service plan authorization form under any circumstances. All service payments must be prior-authorized by a case manager. This section shall be waived if the criteria in (6) are met. (9) Case managers must assess and utilize as appropriate, natural supports, cost-effective assistive devices, durable medical equipment, housing accommodations, and alternative service resources (as defined in OAR 411-015-0005) that may reduce the need for paid assistance. (10) The Department may authorize paid in-home services only to the extent necessary to supplement potential or existing resources within an individual's natural supports system. (11) Payment by the Department for Medicaid home and community-based services are only made for the tasks described in this rule as ADL or IADL tasks. Services must be authorized to meet the needs of an eligible individual and may not be provided to benefit an entire household. (12) An individual who meets the Extended Waiver Eligibility criteria outlined in OAR 411-015-0030 is eligible to receive a maximum total of 10 hours per service period to accomplish ADLs and IADLs.