Or. Admin. Code § 411-014-0020

Current through Register Vol. 63, No. 12, December 1, 2024

Section 411-014-0020 - Eligibility and Limitations for Oregon Project Independence-Medicaid

(1) To be eligible for Oregon Project Independence- Medicaid services, an individual must:

(a) Be age 18 or older;

(b) If aged 18-59, meet the criteria for disability in OAR 461-125-0370 used for the OSIPM;

(c) Meet financial eligibility criteria in OAR chapter 411, division 014 and the OSIPM requirements for individuals in non-standard living arrangements in OAR chapter 461, all divisions unless otherwise covered in OAR 411-014-0025;

(d) Meet the functional impairment level within the service priority levels (1) to (18) as defined in OAR 411-015-0010; and

(e) Reside in an In-home setting as defined in OAR 411-030-0033 and not reside in any of the settings in OAR 411-030-0040(7).

(2) During the implementation phase of Oregon Project Independence-Medicaid, the Department will prioritize individuals at-risk of institutionalization who have been unable to access Oregon Project Independence or whose needs are not being met by Oregon Project Independence.

(3) Individuals under 60 years of age with a diagnosis of an intellectual or developmental disability are not eligible for OPI-M.

(4) Individuals under 60 years of age who have a diagnosis of mental or emotional disorder or substance use disorder are not eligible for OPI-M unless all of the following are met:

(a) The individual has a medical, non-psychiatric diagnosis or physical disability;

(b) The individual's need for services is based on their medical, non-psychiatric diagnosis, or physical disability; and

(c) The individual provides supporting documentation demonstrating that their 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.

(5) Individuals receiving any of the following programs or services through the Department are not eligible for OPI-M services:

(a) 1915(i), 1915(j), or 1915(k) state plan services as defined in Oregon's Medicaid State Plan including but not limited to:

(A) Spousal Pay services as defined in OAR 411-030-0080;

(B) The Independent Choices Program defined in OAR 411-030-0100; and

(C) Shift services as defined in OAR 411-030-0068.

(b) Waivered services under any Oregon 1915(c) waiver;

(c) State Plan Personal Care Services as defined in OAR chapter 411, division 034;

(d) Healthier Oregon Program as defined in OAR 461-135-1080;

(e) Oregon Project Independence as defined in OAR chapter 411, division 032 or any duplicative Older Americans Act funded services;

(6) Individuals receiving the OSIPM under the following may be eligible to receive OPI-M services if they meet all other OPI-M program eligibility criteria:

(a) OAR 461-135-0010(2) Assumed, Continuous and Protected Eligibility: OSIPM, QMB;

(b) OAR 461-135-0830 Eligibility for Disabled Adult Children; OSPIM;

(c) OAR 461-135-0780 Pickle Amendment Clients; OSIPM.

(7) Individuals may receive both the Supplemental Nutrition Assistance Program and OPI-M.

(8) OPI-M services are not intended to replace natural support systems. Paid support is provided if a natural support is unwilling or unable to provide identified services or to supplement unmet needs that the natural support cannot meet.

Or. Admin. Code § 411-014-0020

APD 23-2024, temporary adopt filed 05/20/2024, effective 5/31/2024 through 11/26/2024; APD 65-2024, adopt filed 11/20/2024, effective 11/22/2024

Statutory/Other Authority: ORS 410.070

Statutes/Other Implemented: ORS 410.060, 410.070 & 414.065