OAR 411-027-0025
Payment for Residential Care Facility and Adult Foster Home Services
(1)
SERVICE PAYMENT. The provider must agree to accept an amount determined pursuant to OAR 461-155-0270 (Room and Board Standard; OSIPM) for room and board and a service payment determined by the Department pursuant to OAR 411-027-0020 (Payment Limitations in Home and Community-Based Services) or 411-027-0050 (Exceptions to Payment Limitations in Home and Community-Based Services) as payment in full for all services rendered to an individual.(2)
SERVICE RATES. Service rates are based on an individual’s level of impairment and assessed need for services as documented in CA/PS. Service eligibility levels are assigned based on the degree of assistance an individual requires with activities of daily living and certain procedures that must be performed by a provider.(a)
A base rate is paid for all individuals in accordance with the rate schedule.(b)
Additional add-on payments are made for individuals whose assessed needs meet add-on criteria. Add-on payments are paid in accordance with the rate schedule.(A)
If an individual is eligible for one add-on payment, an add-on payment is made in addition to the base payment.(B)
If an individual is eligible for two add-on payments, a total of two add-on payments are made in addition to the base payment.(C)
If an individual is eligible for three add-on payments, a total of three add-on payments are made in addition to the base payment.(D)
An individual that is eligible for Extended Waiver Eligibility, as defined and authorized in OAR 411-015-0030 (Extended Waiver Eligibility (EWE)) is not eligible for an add-on payment.(c)
Eligibility for add-on payments is made based on individual needs as documented in CA/PS. An individual is eligible for an add-on payment if:(A)
The individual is full assist in mobility or eating or elimination;(B)
The individual demonstrates behavior that pose a risk to the individual or to others and the provider must consistently intervene to supervise or redirect; or(C)
The individual’s medical treatments, as selected and documented in CA/PS, require daily observation and monitoring with oversight by a licensed healthcare professional, no less than quarterly, and the facility has trained staff to provide such service and does provide the service.(3)
PAYMENT RESPONSIBILITIES.(a)
An individual is entitled to retain a personal allowance plus any income disregards pursuant to OAR 461-160-0620 (Income Deductions and Client Liability; Long-Term Care Services or Home and Community-Based Care; OSIPM).(b)
An individual is responsible for payment of the room and board amount pursuant to OAR 461-155-0270 (Room and Board Standard; OSIPM).(A)
An individual eligible for Medicaid under OAR chapter 410, division 200 and eligible for long term care services under OAR 411-015-0100 (Eligibility for Nursing Facility or Medicaid Home and Community-Based Services) living in community based care facilities may be eligible for room and board assistance if the individual’s gross income is less than the room and board amount defined in OAR 461-155-0270 (Room and Board Standard; OSIPM). The Department issues a special needs payment to the facility, on the individual’s behalf, for the difference between the individual’s income and the room and board standard.(B)
An individual eligible for Medicaid under OAR chapter 410, division 200 and receiving room and board assistance must apply for all benefits for which the individual may be eligible, per OAR 410-200-0220 (Requirement to Pursue Assets), to continue to receive the room and board assistance. Individuals must follow all appeal options if applicable.(c)
An individual must contribute any income in excess of the personal allowance, income disregards, and room and board payments to the provider toward the service payment pursuant to OAR 461-160-0610 (Client Liability; OSIPM (except OSIPM-EPD)) and OAR 461-160-0620 (Income Deductions and Client Liability; Long-Term Care Services or Home and Community-Based Care; OSIPM).(4)
The provider may not charge the individual, or a relative or representative of the individual, for items included in the room and board or service payments for any items for which the Department makes payment.(5)
The Department is not responsible for damages to the provider’s home, facility or property, or obligations entered into with the individual.
Source:
Rule 411-027-0025 — Payment for Residential Care Facility and Adult Foster Home Services, https://secure.sos.state.or.us/oard/view.action?ruleNumber=411-027-0025.