OAR 411-015-0015
Current Limitations
(1)
The Department has the authority to establish, by administrative rule, service eligibility within which to manage the Department’s limited resources. The Department is currently able to serve:(a)
Individuals determined eligible for the Medicaid OHP Plus benefit package who are assessed as meeting at least one of the service priority levels (1) through (13) as described in OAR 411-015-0010 (Priority of Paid Services).(b)
Individuals eligible for Oregon Project Independence funded services, if the individual meets at least one of the service priority levels (1) through (18) of OAR 411-015-0010 (Priority of Paid Services).(c)
Individuals needing risk intervention services in areas designated to provide such services. Individuals with the lowest service priority level number under OAR 411-015-0010 (Priority of Paid Services) are served first.(2)
Individuals 65 years of age or older, determined eligible for developmental disability services, or having a primary diagnosis of a mental or emotional disorder, are eligible for nursing facility or Medicaid home and community-based services if:(a)
The individual meets section (1) of this rule; and(b)
The individual is not in need of specialized mental health treatment services or other specialized Department residential program interventions as identified through the mental health assessment process or PASRR process described in OAR 411-070-0043 (Pre-Admission Screening and Resident Review (PASRR)).(3)
Individuals under 65 years of age, determined eligible for developmental disability services, or having a primary diagnosis of a mental or emotional disorder, are not eligible for Department nursing facility services unless determined appropriate through the PASRR process described in OAR 411-070-0043 (Pre-Admission Screening and Resident Review (PASRR)).(4)
Individuals under 65 years of age determined to be eligible for developmental disability services are not eligible for Medicaid home and community-based services administered by the Department’s Aging and People with Disabilities. Eligibility for Medicaid home and community-based services for individuals with intellectual or developmental disabilities is determined by the Department’s Office of Developmental Disability Services or designee.(5)
Individuals under 65 years of age who have a diagnosis of mental or emotional disorder or substance abuse related disorder are not eligible for Medicaid home and community-based services administered by the Department’s Aging and People with Disabilities unless:(a)
The individual has a medical non-psychiatric diagnosis or physical disability;(b)
The individual’s need for services is based on his or her medical, non-psychiatric diagnosis, or physical disability; and(c)
The individual provides supporting documentation demonstrating that his or her need for services is based on the medical, non-psychiatric diagnosis, or physical disability. The Department authorizes documentation sources through approved and published policy transmittals.(6)
Medicaid home and community-based services are not intended to replace a natural support system as defined by OAR 411-015-0005 (Definitions). Paid support is provided if a natural support is unwilling or unable to provide identified services.(7)
Individuals with excess income must contribute to the cost of service pursuant to OAR 461-160-0610 (Client Liability; OSIPM (except OSIPM-EPD)) and 461-160-0620 (Income Deductions and Client Liability; Long-Term Care Services or Home and Community-Based Care; OSIPM).
Source:
Rule 411-015-0015 — Current Limitations, https://secure.sos.state.or.us/oard/view.action?ruleNumber=411-015-0015.