OAR 461-155-0630: Special Need; Community-Based Care; OSIPM

In the Oregon Supplemental Income Program Medical (OSIPM) program: (1) An individual is considered living in a community-based care (see OAR 461-001-0000) facility if the individual resides at one of the following care settings licensed by the Department: (a) Adult Foster Home. (b) Residential Care Facility. (c) Assisted Living Facility. (d) Specialized Living Facility. (e) Group Care Home. (2) If an individual who meets the applicable income requirements begins living in a community-based care facility : (a) Payment for room and board may be authorized during the month of admission at the initial placement, limited to the approved rate. (b) Room and board payments may be paid to the community-based care facility during the temporary absence of the individual subject to the following provisions: (A) Payment for room and board may be initially authorized for up to three months, starting with the month in which the absence began, if all of the following criteria are met: (i) The absence occurs because the individual is admitted to a hospital or nursing home. (ii) The Department determines the intent of the individual to return to the community-based care facility . (iii) The community-based care facility is willing to accept the room and board payment. (iv) The individual does not have sufficient income to pay room and board after contributing available income to the liability (see OAR 461-160-0620), to the extent one is owed. (B) If additional time is needed and the individual continues to meet criteria under paragraph (A) of this subsection, a payment extension of up to three months may be approved in writing by a local office supervisor. (3) Spouses who each receive Supplemental Security Income (SSI) and receive services in a community-based care facility are eligible for a payment in the amount that equals the difference between the OSIPM standard for a one-person need group (see OAR 461-110-0630) and the individual's total countable (see OAR 461-001-0000) income. If one spouse (see OAR 461-001-0000) has income above the OSIPM standard, the excess income is applied to the countable income of the other spouse . (4) Payment for room and board may be authorized for up to three months for an individual who cannot access income due to incapacity subject to the following provisions: (a) Payment under this section is subject to approval by the APD Medicaid Financial Eligibility policy unit. (b) The individual must meet all of the following requirements: (A) When the individual is determined eligible for community-based care , the individual has no legal or financial representative. (B) Payment for room and board is necessary to secure placement. (C) A legal or financial representative is being established. (c) The payment may be extended past the initial three months if the APD Medicaid Financial Eligibility policy unit determines additional time is needed to establish a legal or financial representative. (d) The payment is the difference between the countable income and the room and board standard under OAR 461-155-0270.