OAR 411-380-0030: Eligibility and Limitations for Direct Nursing Services

(1) NON-DISCRIMINATION. An individual may not be denied direct nursing services 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) ELIGIBILITY. To be eligible for direct nursing services, an individual must meet the following requirements: (a) Be 21 years of age or older. (b) Be an Oregon resident who meets the residency requirements in OAR 461-120-0010. (c) Be determined eligible for developmental disabilities services by a Community Developmental Disabilities Program in the county of origin as described in OAR 411-320-0080. (d) Be receiving one of the following: (A) A Medicaid Title XIX benefit package through OSIPM or HSD medical programs. Individuals receiving Medicaid Title XIX through HSD medical programs for services in a nonstandard living arrangement as defined in OAR 461-001-0000 are subject to the requirements in the same manner as if the individual requested these services under OSIPM, including the rules regarding: (i) The transfer of assets as set forth in OAR 461-140-0210 through 461-140-0300. (ii) The equity value of a home which exceeds the limits as set forth in OAR 461-145-0220. (B) A benefit package through the Healthier Oregon medical program. (e) Be determined to meet the ICF/IID Level of Care as defined in OAR 411-317-0000. (f) Based on a functional needs assessment, require oversight for complex health management support needs. (g) Score 45 or higher on the Direct Nursing Services Criteria completed by the Department. (h) Have health impairments requiring long-term direct nursing services determined medically necessary and appropriate based on the order of a physician. (3) ACUITY LEVELS. The amount of hours available for direct nursing services is based on the following acuity levels as measured by the Direct Nursing Services Criteria: (a) Level 1: Score of 75 or above and on a ventilator for 20 hours or more per day = up to a maximum of 554 hours per month for direct nursing services. (b) Level 2: Score of 70 or above = up to a maximum of 462 hours per month for direct nursing services. (c) Level 3: Score of 65 to 69 = up to a maximum of 385 hours per month for direct nursing services. (d) Level 4: Score of 60 to 64 = up to a maximum of 339 hours per month for direct nursing services. (e) Level 5: Score of 50 to 59 or if an individual requires ventilation for sleeping hours = up to a maximum of 293 hours per month for direct nursing services. (f) Level 6: Score of 45 to 49 = up to a maximum of 140 hours per month for direct nursing services. (4) SERVICE DELIVERY. (a) Except as limited under section (5)(a) of this rule, direct nursing services may be delivered at the following: (A) An individual's home. (B) An adult foster home as described in OAR chapter 411, division 360. (C) A licensed 24-hour residential setting as described in OAR chapter 411, division 325. (D) An employment setting as described in OAR chapter 411, division 345. (E) A day service site. (F) In the community. (b) The hours for direct nursing services for individuals accessing other attendant care services at an employment setting or in the community, are prorated based on the acuity level of the individual between the employment setting and the home of the individual. (5) LIMITATIONS. (a) Direct nursing services are excluded for the following: (A) An individual while in a medical or psychiatric hospital. (B) An individual residing in a school, nursing facility, assisted living facility, or residential care facility. (b) Direct nursing services may not substitute for, or duplicate, other direct or private duty nursing services provided by State Plan or third party resources. (c) Direct nursing services provided concurrently with hospice services provided under OAR 410-142-0240 or home health care services provided under OAR 410-127-0040 are not reimbursable under these rules. (d) Direct nursing services are not covered in conjunction with any intravenous, enteral, or parenteral related skilled nursing services as described in OAR 410-148-0300. (e) Direct nursing services may not duplicate school-based nursing services covered under the provision of the Individuals with Disabilities Education Act (IDEA). (f) Direct nursing services do not include any of the following: (A) Hours spent receiving professional training or career development. (B) Administrative functions such as non-individual-specific services, quality assurance reviews, authoring health related agency policies and procedures, or providing general training for caregivers. (C) Travel time spent in transit to or from the residence of the provider. (D) Long-term care community nursing services, including nurse delegations, as described in OAR chapter 411, division 048.