OAR 411-455-0040: Exceptions

(1) An individual, or their legal or designated representative as applicable, may request an exception either orally or in writing if they believe the maximum monthly hour limitation is not meeting, or will not meet, the individual's support needs. (2) The case manager must assist the individual, or their legal or designated representative as applicable, with the exception request including completing the Funding Review and Exceptions Request (form 0514DD) and gathering required supporting documents. The Funding Review and Exceptions Request must: (a) Include an explanation of any change in the individual’s level of assistance, available resources, and relevant documentation to support the reasons for why the maximum monthly hour limitation is not meeting, or will not meet, the individual's support needs. (b) Provide a clear description of how the individual’s support needs are being met throughout a day, including available alternative resources and natural supports as defined in OAR 411-317-0000. (3) Prior to submitting the Funding Review and Exceptions Request to ODDS, the case manager must review the individual's current needs assessment for any change in the individual’s level of assistance and available resources to meet those needs documented in the individual's ISP or Annual Plan, SPPC Service Authorization Plan, and any other documentation in the individual's service record as described in OAR 411-415-0110. (a) If the assessment was conducted less than six months from the date of the exception request, the case manager must conduct a reassessment when requested by the individual, or their legal or designated representative as applicable, to determine the individual’s current level of assistance and proceed with service authorization in accordance with OAR 411-455-0030. (b) If the assessment was conducted at least six months from the date of the exception request, the case manager must conduct a reassessment to determine the individual’s current level of assistance and proceed with service authorization in accordance with OAR 411-455-0030. (4) ODDS has up to 30 calendar days upon receipt of a Funding Review and Exceptions Request and relevant supporting documentation identified in section (2) of this rule to approve or deny the exception request. (5) ODDS may approve or deny the exception request based on review of the individual’s assessed support needs and available resources to meet those needs. (a) APPROVALS. ODDS may approve an exception for the individual’s documented support needs that may be met by qualified providers within the exception limits described in section (6) of this rule. (b) DENIALS. (A) ODDS may deny an exception when: (i) The request is not within the exception limits described in section (6) of this rule. (ii) The individual’s assessed level of assistance may not be met by qualified providers within the exception limits described in section (6) of this rule. (iii) The requested assistance is not an allowable ADL or IADL task as described in OAR 411-455-0050, or an assistance type as described in OAR 411-455-0010. (iv) The exceptional support needs may be met through alternative resources or natural supports, as defined in OAR 411-317-0000, available to the individual. (B) When an exception request is denied, ODDS must provide a written Notification of Planned Action (form 0947) to the individual as described in OAR 411-318-0020 and offer other options of developmental disabilities services to the individual as described in OAR 411-415-0070(9). (6) EXCEPTION LIMITS. (a) Approval for additional SPPC service hours shall be based on the frequency of the support needs and the amount of support required for each ADL or IADL task to ensure the health and safety of the individual. Assistance types must be: (A) Hands-on assistance as described in OAR 411-455-0010. (B) On-going supervision as described in OAR 411-455-0010. (b) Up to two additional hours for each task per month may be granted for hands-on assistance. (c) Up to five additional hours for each task per month may be granted for on-going supervision.