OAR 411-300-0120: Eligibility for CIIS

(1) NON-DISCRIMINATION. A child may not be denied CIIS or otherwise discriminated against on the basis of race, color, religion, sex, gender identity, sexual orientation, national origin, marital status, age, disability, source of income, duration of Oregon residence, or other protected classes under federal and Oregon Civil Rights laws. (2) ASSESSMENT. An assessment of a child for a determination of eligibility for entry into CIIS may be requested by the child's services coordinator or legal guardian. (3) GENERAL ELIGIBILITY. To be eligible for CIIS, a child must meet the following requirements: (a) Be under the age of 18 or under the age of 21 for a young adult who meets the requirements in section (6) of this rule and is accessing private duty nursing services only. (b) Be an Oregon resident who meets the residency requirements in OAR 461-120-0010. (c) Be receiving: (A) A Medicaid Title XIX benefit package through OSIPM or HSD medical programs; or (B) A benefit package through the Healthier Oregon medical program. (d) Contribute to the cost of services in accordance with OAR 461-160-0610 and OAR 461-160-0620, for a child with excess income. (e) Reside in the family home (except for a child or young adult living in foster care who is eligible for private duty nursing services only). (f) Be safely served in the family home. This includes, but is not limited to, a qualified primary caregiver demonstrating the willingness, skills, and ability to provide direct care as outlined in an ISP in a cost effective manner, as determined by a services coordinator, and participate in planning, monitoring, and evaluation of the services provided. (4) ELIGIBILITY - ICF/ID BEHAVIORAL PROGRAM. To be eligible for the ICF/ID Behavioral Program, a child must: (a) Meet the general CIIS eligibility requirements in section (3) of this rule. (b) Be determined eligible for developmental disabilities services by the CDDP of the county of origin as described in OAR 411-320-0080. (c) Meet the ICF/IID Level of Care as defined in OAR 411-317-0000. (d) Be accepted by the Department by scoring 200 or greater on the Behavior Criteria within 90 calendar days prior to starting services and maintain a score of 200 or greater as determined annually by a reassessment. (5) ELIGIBILITY - MEDICALLY FRAGILE CHILDREN'S PROGRAM. To be eligible for the Medically Fragile Children's Program, a child must: (a) Meet the general CIIS eligibility requirements in section (3) of this rule. (b) Meet the Hospital Level of Care as defined in OAR 411-317-0000. (c) Be accepted by the Department by scoring 45 or greater on the MFC Clinical Criteria prior to starting services, have a status of medical need likely to last for more than two months, and maintain a score of 45 or greater on the MFC Clinical Criteria as assessed every six months. (6) ELIGIBILITY - PRIVATE DUTY NURSING SERVICES THROUGH THE MEDICALLY FRAGILE CHILDREN'S PROGRAM. A child or young adult not enrolled in the Medically Fragile Children's Program, who resides in a foster home or their family home, may be eligible for private duty nursing. (a) To be eligible for private duty nursing, the child or young adult must: (A) Meet the general CIIS eligibility requirements in section (3) of this rule. (B) Be accepted by the Department by scoring 45 or greater on the MFC Clinical Criteria prior to starting services, have a status of medical need likely to last for more than two months, and maintain a score of 45 or greater on the MFC Clinical Criteria as assessed every six months. (b) A child or young adult residing in a foster home is eligible for only the private duty nursing services described in OAR 411-300-0150. (c) A young adult residing in a family home is eligible for only the private duty nursing services described in OAR 411-300-0150. (7) ELIGIBILITY - MEDICALLY INVOLVED CHILDREN'S PROGRAM. To be eligible for the Medically Involved Children's Program, a child must: (a) Meet the general CIIS eligibility requirements in section (3) of this rule. (b) Meet the Nursing Facility Level of Care as defined in OAR 411-317-0000. (c) Be accepted by the Department by scoring 100 or greater on the Medically Involved Criteria and maintain an eligibility score of 100 or greater as determined annually by a reassessment. (d) Require services offered through the Medically Involved Children's Waiver. (8) EXIT. A child may be exited from CIIS in any of the following circumstances: (a) The child is exited from case management services as described in OAR 411-415-0030. (b) The child no longer meets the general CIIS eligibility criteria in section (3) of this rule. (c) The child no longer meets the eligibility requirements for any of the following: (A) The ICF/ID Behavioral Program described in section (4) of this rule. (B) The Medically Fragile Children’s Program described in section (5) of this rule. (C) The Medically Involved Children's Program described in section (7) of this rule. (d) A young adult no longer meets criteria for the private duty nursing services described in OAR 411-300-0150. (e) The Department has sufficient evidence the parent or guardian has engaged in fraud or misrepresentation, failed to use resources as agreed upon in the ISP, refused to cooperate with documenting usage of Department funds, or otherwise knowingly misused public funds associated with CIIS. (f) The child is incarcerated or admitted to a medical hospital, psychiatric hospital, sub-acute facility, nursing facility, intermediate care facility for individuals with intellectual disabilities, foster home, or other 24-hour residential setting and it is determined the child is not returning to the family home after 90 consecutive days. (g) At the oral or written request of a parent or guardian to end the service relationship. The services coordinator must document the request to end the service relationship in the file of the child. (h) The child is not safely served in the family home as described in section (3)(f) of this rule. (i) The services coordinator is not able to locate the child and their parent or guardian. (j) The parent or guardian has not responded after 30 calendar days of repeated attempts by a services coordinator to complete ISP development or monitoring activities, including participation in a functional needs assessment. (k) The child does not reside in Oregon. (9) TRANSITION DUE TO INELIGIBILITY FOR CIIS. (a) A child who no longer meets eligibility criteria must be transitioned from CIIS no later than 30 calendar days from the date of the assessment that determined ineligibility for the program. (b) The CIIS program shall assist families to identify alternative resources. (c) In the event enrollment in CIIS is ended, a written Notification of Planned Action must be provided as described in OAR 411-318-0020. (10) WAIT LIST. If the maximum number of children allowed on an approved Model Waiver are enrolled and being served in the program, the Department may place a child eligible for CIIS on a wait list. A child on the wait list may access other Medicaid or General Fund services for which the child is determined eligible. (a) The date the Department has received the initial completed application for CIIS determines the order on the wait list. (b) A child who was previously enrolled in CIIS and currently meets the criteria for eligibility as described in section (3) of this rule, is put on the wait list as of the date the original application for CIIS was complete. (c) The date the application for CIIS is complete is the date the Department receives the complete referral. (d) A child on the wait list is served on a first come, first served basis as space in CIIS allows. A reassessment is completed prior to entry to determine current eligibility. A child must be: (A) Reassessed for the ICF/ID Behavioral Model Waiver if the current assessment is more than 90 calendar days old. (B) Reassessed for the Medically Involved Children's Waiver if the current assessment is more than 90 calendar days old. (C) Newly assessed for the Medically Fragile Model Waiver. (e) A child on the wait list is prioritized for entry into the Medically Involved Children's Waiver if the child is currently residing in a nursing facility for long-term care and the family of the child wishes the child to return home, or the child resides in the community and is at imminent risk of placement in a nursing facility. An evaluation is completed prior to entry to determine current eligibility.