OAR 461-155-0700: Special Need; Personal Incidentals and Room and Board Allowances; OSIPM

In the Oregon Supplemental Income Program Medical (OSIPM) program: (1) In the following circumstances, personal incidentals and room and board allowances may be paid for an individual to reside in a community-based care facilit y (see OAR 461-155-0630(1)) to avoid placement in a nursing facility or leave a nursing facility or an acute care hospital, when an individual meets the requirements of one of the following subsections: (a) Is determined to be eligible based on a disability determination made by the Department (see OAR 461-125-0370). (A) To receive this payment, the individual must pursue Supplemental Security Income (SSI) by making application with the Social Security Administration (SSA) and appealing denials until SSA makes a final administrative decision. If SSI is denied at the final SSA administrative level, the individual is no longer eligible for this payment. (B) The payment is the difference between the countable (see OAR 461-001-0000) income of the individual and the OSIPM program adjusted income standard (see OAR 461-155-0250). (b) Is leaving a nursing facility and limited to a maximum SSI payment of $30 or to a maximum Veterans benefit payment of $90. (A) To receive this payment, the individual must pursue reinstatement back to the full SSI standard with the Social Security Administration or the full rate of pension with the Veteran Affairs Office. (B) The payment is the difference between the countable income of the individual and the OSIPM program adjusted income standard (see OAR 461-155-0250). (c) Is a qualified non-citizen under OAR 461-120-0125 who is not eligible for SSI due to not meeting the requirements to become a naturalized citizen within the SSI time limit. (A) The individual must pursue naturalization. (B) The payment is the difference between the countable income of the individual and the OSIPM adjusted income standard (see OAR 461-155-0250). (d) Does not have sufficient income to divert to the community spouse (see OAR 461-001-0030) due to the difference between the personal needs allowance related to a nursing facility placement and the personal needs allowance and room and board related to a community-based care facility placement. The allowance is issued only when the individual or community spouse requests or chooses a nursing facility placement rather than a community-based care facility placement because the community spouse needs the resulting higher diversion amount to meet his or her monthly expenses. (A) For all individuals, the allowance is the difference between the amount of the individual's income that would be available to divert to the community spouse under a nursing facility placement and the amount of the individual's income available under the community-based care facility placement, using the liability calculation as outlined in OAR 461-160-0620. (B) For an individual under a community-based care facility placement whose income is less than the adjusted OSIPM program standard, the allowance is the amount calculated under paragraph (A) of this subsection plus the difference between the OSIPM program adjusted income standard and the individual's countable income. (2) Room and board allowance (see OAR 461-155-0270), without personal incidentals, may be paid for an individual to reside in a community-based care facilit y to avoid placement in a nursing facility, when an individual is leaving a public institution (see OAR 461-135-0950) and the individual’s SSI is suspended, subject to the following provisions: (a) The individual’s SSI must have been suspended due to placement in a public institution. (b) The individual must pursue reinstatement of SSI, and verification must be provided to the Department. (c) The payment is the difference between the countable income of the individual and the OSIPM Room and Board Standard (see OAR 461-155-0270). (d) If SSI is reinstated or reinstatement of SSI is denied, the individual is no longer eligible for this allowance. (3) The payment amount is prorated in the first month for an individual who moves to a community-based care facility on any day other than the first day of the month.