OAR 582-070-0030: Limitations of Payments

NOTE: For medical and related services refer also to OAR 582-075 and 582-080; and, for providers of community rehabilitation services refer also to OAR 582-010. (1) Payment in Full: Vendors providing any services authorized by the Program shall not make any charge to or accept any payment from the individual or their family for such services unless the amount of the service charge or payment to be borne by the individual is previously agreed to by the individual or their family, known to and, where applicable, approved by the Program. (2) Client financial participation and the financial needs test: Except as expressly exempted, services funded by the Program are subject to client financial participation. Individuals shall be required to contribute financially as set forth in OAR 582-070-0030. The contribution requirements apply for individuals submitting applications for services and for annual individualized plan for employment (IPE) reviews. (a) Individual participation in service costs encourages commitment to and investment in a successful vocational rehabilitation process. Service equity is advanced and limited Program resources are expanded when the financial contribution is individualized. (b) Except as provided in OAR 582-070-0030(2)(j) and (k), the following individuals are exempt from any mandatory client financial participation: (A) Any individual who has been determined eligible for and is currently receives Social Security Benefits under Title II (Social Security Disability Insurance, SSDI) or Title XVI (Supplemental Security Income, SSI) of the Social Security Act; (B) Recipients of qualifying needs-based governmental public assistance programs, including Self Sufficiency Cash Benefits, Oregon Health Plan (OHP), Temporary Assistance for Needy Families (TANF), and Supplemental Nutrition Assistance Program (SNAP), but excluding financial aid for post-secondary education; (C) Unhoused or transient individuals. (c) Except as provided in OAR 582-070-0030(2)(j) and (k), the following services are exempt from client financial participation: (A) Assessment to determine eligibility, vocational rehabilitation needs, or priority for services, including assessment by personnel skilled in rehabilitation technology; (B) Vocational rehabilitation counseling and guidance, including information and support services to assist an individual in exercising informed choice; (C) Referral and other services necessary to assist applicants and eligible individuals to secure needed services from other agencies, including other components of the statewide workforce investment system and to advise those individuals about client assistance programs; (D) Job related services, including job search and placement assistance, job retention services, follow-up services, and follow-along services; (E) Auxiliary aids or services, required to participate in the vocational rehabilitation program, such as interpreter services, including sign language and oral interpreter services, for individuals who are deaf or hard of hearing, and tactile interpreting services for individuals who are deaf-blind provided by qualified personnel. Note: Hearing aids are not considered auxiliary aids. See OAR 582-001-0010(9). (d) Under the financial needs test, individuals with annual family income of less than 300 percent of the federal poverty guidelines are not subject to client financial participation. (A) The Program will publish the client financial participation rates annually. (B) This transmittal shall determine the mandatory contribution to document in the individualized plan for employment (IPE). (e) Client financial participation shall be determined at the time that the IPE is written, and annually thereafter. Client financial participation shall not exceed the annual cost of non-exempt services as described in the IPE. (f) The Program shall use the following definitions to calculate client financial participation: (A) "Income" means the adjusted gross income from the most recent federal tax return. (B) "Family income" means the income from the individual, the spouse of the individual if residing with the individual and includes parental income if the individual is under 26 and living with a parent. (C) "Federal poverty guidelines" means the current poverty guidelines of the United States Department of Health and Human Services. (D) "Size of the family unit" means, for the purpose of selecting the appropriate federal poverty guideline, those family members residing with the individual or claimed on federal taxes as dependents. (E) “Disability-related expenses” means non-reimbursed deductions excluded from individual’s income for the purpose of determining the client financial participation. These include, but are not be limited to: (i) Medical expenses (including co-payments) (ii) Therapeutic treatments (iii) Specialized equipment (iv) Specialized care (v) In-home care (vi) Loss of work time (vii) Access to resources that impact where they live and work (F) “Participant contribution rate” means the payment rate that Program participants shall contribute, if a contribution is required. (i) Disability related deductions and the annual federal poverty guideline allowance shall be subtracted from the individual’s adjusted gross annual income. This resulting amount shall be multiplied by one percent to provide the client contribution for the individualized plan for employment. The contribution shall not exceed the annual cost of non-exempt services to the Program. (ii) Formula: (Income – (non-reimbursed disability related deductions + annual federal poverty guideline allowance)) * 1.0% if greater than zero and less than the annual cost of non-exempt services to the Program. (g) If the individual or their family choose not to share information about their income as part of the calculation of the client financial participation, an annual, mandatory individual contribution of $3,500 shall be established, not to exceed the annual cost of non-exempt services to the Program. (h) The maximum contribution is the lesser of the amount determined by the contribution formula (OAR 582-070-0030(f)(F)) or $3,500 annually. (i) Subsequent financial needs tests shall be conducted: (A) During the annual review of the individualized plan for employment (IPE), and, (B) May also be conducted if there is a change in the financial situation of either the individual or the family unit that impact the client financial participation rate. (j) A hardship waiver shall be considered: (A) When the counselor identifies other information related to the individual's financial situation that negatively affects the individual's ability to participate in the cost of the rehabilitation program; or, (B) If requiring the expected financial contribution will result in undue delay in the rehabilitation program. (C) In determining whether to make an adjustment for hardship, the Program may consider the individual's current income and the reasons for the request. If the hardship justifies an exception, the Program may delay or waive all or part of the individual's financial contribution. (D) Examples of hardship would include: (i) A change in the individual’s household income from the previous year, such as job loss, injury or illness that results in the individual’s ability to maintain prior income level. (ii) If the individual’s income has remained stable but there have been significant financial hardships within the last 12 months that are involuntary or out of the individual’s control. In this case, extenuating circumstances may be considered. (E) To request a hardship waiver the counselor shall: (i) Provide individual’s documentation of the reasons for the hardship waiver to their supervisor; and, (ii) Obtain written approval of their supervisor; (iii) Maintain both the documentation of circumstances and written approval in the case service record. (k) All authorizations for services must meet the rehabilitation needs of the individual and shall be of the most reasonable and satisfactory quality at the lowest available cost. (A) In the circumstance when an individual prefers an upgrade, enhancement, or optional feature that results in a higher cost but is not required to satisfy the rehabilitation needs that justify the expenditure, the Program may agree to allow the individual to pay the difference in cost of the item or service. (B) In this situation, payment is required regardless of any exempt status that might apply to the individual or item; and, (C) Any payments by the individual in this situation do not count toward any applicable mandated client financial participation. (l) An IPE may include voluntary client contributions. (3) Student Financial Aid: The Program assures that maximum effort is made by the individual to secure student financial aid or assistance for any approved training in institutions of higher education. Maximum effort includes making timely application for such grant, scholarship, or community resource assistance on a consistent basis and utilizing such benefits as are available in lieu of Program funding. (a) Coverage: All individuals, including graduate students, must apply for all financial aid benefits each academic year. (A) All need-based grants, including Pell Grants and Student Employment Opportunity Grants, must be used to pay for educational costs, including tuition and books, before an individual may utilize Program funds for this purpose. (B) The requirement to apply all funds and grants does not apply to merit-based grants, merit-based scholarships or loans. However, individuals may voluntarily elect to use these funds, as well as work study and loans for this purpose. (b) Other comparable benefits or services: If a third party (e.g., employer, insurance company, Workers’ Compensation Division) is required to or agrees to pay or reimburse the Program all of the case service rehabilitation costs of the individual, the financial aid grant offer need not be applied against the plan costs nor treated as a comparable benefit; (c) Late Applications: Pending determination of student aid by the financial aid officer, Program funds can be expended for education-related expenses between the date of application for financial aid and determination of the individual's eligibility for federal student aid provided that such expenditures are reduced by any amounts of comparable benefits subsequently received, excepting student loans; (d) Duplicate Payments: When student financial aid is approved, arrangements must be made promptly to reduce projected Program payments and/or recover duplicate payments; (4) For Injured Workers: The Program shall provide only for the cost of those rehabilitation services which are not the responsibility of the employer, insurer, or workers covered under the Oregon Worker's Compensation Division. (5) Maintenance: The Program shall not provide maintenance except for additional costs incurred while participating in authorized services, such as when the individual must maintain a second residence away from the regular household in order to achieve a rehabilitation goal. Such maintenance shall be provided according to the provisions under OAR 582-070-0020(4), 582-001-0010(47), and 34 CFR 361.5(c)(34). (6) Physical and Mental Restoration Services: Are provided only to improve a diagnosed physical or mental condition that presents a substantial impediment to employment for the eligible individual. All authorized services must be essential for the individual's achievement of an employment outcome. All support and authorization for physical and mental restoration services must follow payment parameters as set forth in OAR 582-075. (a) Prescription Medications: (A) When a licensed health care professional who has the authority to prescribe drugs recommends prescription medication, if practical, the lowest price (e.g., generic) shall be obtained prior to issuing an authorization; (B) Controlled substances require a prescription; an attending physician's statement under ORS 475.309(2)(a) does not qualify as a prescription. (b) Dental Services: Dental care may be provided by the Program when the condition of teeth or gums imposes a major impediment to employment (e.g., endangers health). Dentures, when necessary for employment, may be purchased from licensed dentists or certified denturists; (c) Eye Glasses: Eye glasses may be purchased when determined essential for evaluation of eligibility or the achievement of the employment outcome, limited to basic frames and lenses unless other features are medically required (e.g., sun glasses, tints, coatings, contact lenses); (d) Wheelchairs: The Program may purchase a wheelchair when the equipment is required to reduce or eliminate a disability related functional limitation that is a substantial impediment to employment. Wheelchairs must be prescribed by a qualified medical specialist; (e) Hearing Aids. The Program may provide hearing aids only when: (A) Necessary to reduce or eliminate a substantial impediment to employment for the eligible individual. (B) Essential to complete an evaluation necessitated for Program eligibility or plan services; (C) All hearing services must be diagnosed, provided and fit in accordance with current Program Policy. (D) Unless hearing aids are required to complete a Program application, the purchase of these devices must be completed as a plan service. (f) Other Prosthetic Devices: Prosthetic devices may be purchased only when prescribed by appropriately licensed medical professionals; (g) Psychotherapy: Group or individual psychotherapy may be provided in those instances when required for a person to reach an employment outcome and when an immediate and positive goal related impact is anticipated. A specific number of sessions or a specified time limit is required. The Program may limit these services to those recommended by a Program psychological or psychiatric consultant; (h) Physical or mental restoration services shall not be provided by the Program for the treatment of an acute or chronic medical complication or emergency unless these are associated with or arise out of the provision of physical or mental restoration services in the IPE or are inherent in the condition under treatment as described in the IPE. (i) Corrective surgery or therapeutic treatment shall not be provided or funded by the Program if it is not likely within a reasonable period to correct or substantially modify a stable or slowly progressive physical or mental impairment that constitutes a substantial impediment to employment. (7) Services Not Provided: The Program shall not authorize or provide funding or reimbursement for the following services: (a) Any individual-incurred debt; (b) Any services obtained by the individual prior to the date of application; (c) Purchase of land or stationary buildings; (d) Fines or penalties. Examples include traffic violations, parking tickets, library fines. (e) Breakage fees and other refundable deposits; (f) Contributions and donations; (g) Entertainment costs; (h) Payments to credit card companies; (i) Authorization to supermarkets or grocery stores for food items; (j) Warranties. (A) Examples of warranties that are not permitted: (i) Extended warranties or service contracts for vehicle modifications (ii) Extended warranties or service contracts for hearing aids (B) Examples of warranties that are permitted are items that are sold with an implied warranty as part of the manufacturing process: (i) Tools that are sold with a lifetime warranty (ii) Products that are sold with a money back guarantee (k) Maintenance outside of the definition as set forth in 34 CFR 361.5(c)(34). (l) Services prior to eligibility determination unless they are required to complete the eligibility determination and priority for service. (8) The Program shall not contract with individuals receiving Program services, except: (a) When the individual is an active vendor for the Program prior to application for Program services. (b) Contracted services shall not be authorized in the region or community from which the individual is provided services.