OAR 411-032-0020
Eligibility and Determination of Authorized Services
(1)
ELIGIBILITY.(a)
In order to qualify for authorized services from an AAA or service provider, each eligible individual must:(A)
Be 60 years old or older or be under 60 years of age and diagnosed as having Alzheimer’s Disease or a related disorder;(B)
Not be receiving financial assistance or Medicaid, except food stamps, or Qualified Medicare Beneficiary or Supplemental Low Income Medicare Beneficiary Programs; and(C)
Meet the requirements of the long-term care services priority rules in OAR chapter 411, division 015.(b)
Eligibility determination is required before any individual may receive authorized services from an AAA or service provider. The documentation required by OAR 411-032-0015 (Data Collection, Records, and Reporting) must be obtained before an individual under the age of 60 may be determined to be eligible.(c)
Eligibility determination is the responsibility of the AAA. In those instances when eligibility determination is performed by an agency other than the AAA, the AAA must have in place a system for evaluating the eligibility determination process, including an independent review by the AAA of a representative sample of cases.(d)
Any individual residing in a nursing facility, assisted living facility, residential care facility, or adult foster home setting is not eligible for authorized services. This does not restrict the ability to move an eligible individual from such institutions to their home to receive authorized services, when judged more appropriate, based on medical, financial, physical, functional, and social considerations.(e)
Any individual residing in a living setting that offers any services authorized under OAR 411-032-0010 (Authorized Services and Allowable Costs) is limited to receiving OPI authorized services that are not available in that setting.(f)
The Department determines the factors that constitute an individual being at risk of institutionalization. These factors are currently defined in the long-term care services priority rules, OAR chapter 411, division 015. These factors must be utilized by each AAA and service provider.(g)
Applicants must receive written notification of eligibility determination.(2)
SERVICE DETERMINATION.(a)
Service determination rests with the AAA. In those instances when service determination is performed by an agency other than the AAA, the AAA must have in place a system for evaluating the service determination process, including an independent review by the AAA of a representative sample of cases.(b)
Service determination is based on each individual’s financial, physical, functional, medical, and social need for such services and in accordance with OAR chapter 411, division 015.(c)
Service determination provided under OPI is limited to the authorized services allowed by these rules.(d)
Service determination is made:(A)
After eligibility determination; and(B)
At regular intervals but not less than once every twelve months.(e)
Individuals must receive written notification of the service determination:(A)
Notice must include the maximum monthly hours of authorized service, the hourly and maximum monthly fee, the service rate, and provider contact information.(B)
Written notification of the service determination must be provided to the individual upon initial service determination, at annual reassessment, and when there are changes to the service determination.(3)
PRIORITY FOR AUTHORIZED SERVICES.(a)
An AAA may establish local priorities for OPI authorized services. The AAA’s local priorities cannot conflict with this rule. In the event of a grievance, this rule takes precedence over local priorities.(b)
Priority for authorized services is:(A)
Maintaining eligible individuals already receiving authorized service as long as their condition indicates the service is needed.(B)
Individuals screened utilizing a Department authorized tool that measures risk for out of home placement based on an individual’s financial, physical, functional, medical, and social service needs. Individuals with the highest risk of out of home placement are given priority.(4)
APPEALS. Individuals for whom services are denied, disallowed, or reduced through eligibility determination or service determination are entitled to request review of the decision through the AAA grievance review procedure set forth in policy.(a)
Individuals must continue to receive authorized services until the disposition of the local AAA grievance review.(b)
The AAA must provide the applicant with written notification of the grievance review determination decision.(c)
Applicants who disagree with the results of the AAA grievance review have a right to an administrative review with the Department, pursuant to ORS chapter 183. This information is provided to the applicant in a written notification at the time of the grievance review decision.(d)
Applicants requesting an administrative review from the Department are not eligible for continued OPI authorized.(e)
All individuals, including those who may have previously been terminated from OPI, have the right to apply for OPI authorized services at any time.
Source:
Rule 411-032-0020 — Eligibility and Determination of Authorized Services, https://secure.sos.state.or.us/oard/view.action?ruleNumber=411-032-0020.