Or. Admin. Code § 411-016-0005

Current through Register Vol. 63, No. 10, October 1, 2024

Section 411-016-0005 - [Effective until 11/26/2024] Definitions

Unless the context indicates otherwise, the following definitions apply to the rules in OAR chapter 411, division 016:

(1) "Activities of Daily Living (ADL)" mean those personal functional activities required by an individual for continued well-being, which are essential for health and safety and defined in OAR 411-015-0006. Activities include bathing and personal hygiene, cognition, dressing and grooming, eating, elimination, and mobility

(2) "Adult" means any person at least 18 years of age.

(3) "Adult Day Services (ADS) Program" means a community-based group program designed to meet the needs of adults needing assistance with ADLs described in OAR chapter 411, division 066.

(4) "Alternative Service Resources" means other possible resources for the provision of services to meet an individual's needs. Alternative service resources include, but are not limited to, natural supports, risk intervention services, or other community supports. Alternative service resources are not paid by Medicaid.

(5) "Area Agency on Aging (AAA)" means the Department designated agency charged with the responsibility to provide a comprehensive and coordinated system of services to older adults and adults with disabilities in a planning and service area. The term Area Agency on Aging (AAA) is inclusive of both Type A and Type B AAAs as defined in ORS 410.040 to 410.300.

(a) "Type A Area Agency on Aging" means an Area Agency on Aging for which either the local government or the area agency board does not agree to accept local administrative responsibility for Title XIX Medicaid, except OPI-M; and that provides a service to adults.

(b) "Type B Area Agency on Aging" means an Area Agency on Aging:

(A) For which the local government agrees to accept local administrative responsibility for Title XIX Medicaid;

(B) That provides a service to older adults or to older adults and persons with disabilities who require services similar to those required by older adults; and

(C) Are one of two models of Type B AAA's-Type B Contract or Type B Transfer:

(i) Type B Contract- Staff are employed by the AAA and only administer Older Americans Act, Oregon Project Independence and Oregon Project Independence-Medicaid services case management services.

(ii) Type B Transfer- Staff are employed by the AAA and administer all of the following programs: Medicaid, financial services, Supplemental Nutrition Assistance Program, adult protective services, regulatory programs, Older Americans Act, Oregon Project Independence and all Oregon Project Independence-Medicaid services.

(6) "Assistive Devices" means any category of durable medical equipment, mechanical apparatus, electrical appliance, instrument of technology, service animal, general household items, or furniture used to assist and enhance an individual's independence in performing any activity of daily living.

(7) "Assistive Technology" means any item, piece of equipment, technology, system, whether acquired commercially, modified, or customized, that is used to achieve, increase, maintain, or improve the functional capabilities of an individual, that provides additional security and support to an individual, replaces the need for human interventions or enables an individual to self-direct their care and maximize their independence. Training on using the technology should be offered to the individual.

(8) "Assisted Transportation" means escort services that aid an individual who has difficulties (physical or cognitive) using regular vehicular transportation and includes those services and supports provided so that the individual may access their local community to engage in services necessary to meet their Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). Assisted Transportation must be prior authorized by the Services Case Manager as part of a comprehensive service plan.

(9) "Care Setting" means a Medicaid contracted facility where a Medicaid eligible individual resides and receives services. Care settings include adult foster homes, residential care facilities, assisted living facilities, specialized living contracted residences, and nursing facilities.

(10) "Caregiver Education and Training" means education and training programs and services to increase an unpaid caregiver's skills in providing care and supports unique to the consumer receiving unpaid caregiver services.

(11) "Case Management and Service Coordination" means a service designed to individualize and integrate social and health care options with an individual being served. The goal of service coordination is to provide access to an array of service options to assure appropriate levels of service and to maximize coordination in the service delivery system.

(12) "Chore Services" means assistance such as heavy housework, yard work, or sidewalk maintenance provided on an intermittent or one-time basis to assure health and safety.

(13) "Client Assessment and Planning System (CA/PS)" means:

(a) The single-entry data system used for -

(A) Completing a comprehensive and holistic assessment;

(B) Surveying an individual's physical, mental, and social functioning; and

(C) Identifying risk factors, individual choices and preferences, and the status of service needs.

(b) The CA/PS documents the level of need and calculates the individual's service priority level in accordance with these rules and accommodates individual participation in service planning.

(14) "Community Caregiver Supportive Services" means supports and services that assist the individual and their unpaid caregivers to sustain their caregiving relationship and natural support systems. These supportive services directly benefit the individual by sustaining the unpaid caregiver's health, improving the unpaid caregiver's wellbeing and reducing stress. This may help prevent abuse, neglect and transitions to more intensive levels of care.

(15) "Community Transportation" means non-medical transportation provided by a service provider with a Medicaid provider number and prior authorized as part of an OPI-M service plan by a Services Case Manager.

(16) "Conflict-free Case Management" means that assessment and coordination of services are separate from the delivery of services, with the goal to limit any conscious or unconscious bias a care manager or agency may have, and ultimately promote the individual's choice and independence.

(17) "Cost Effectiveness or cost-effective" means being responsible and accountable with Department resources. This is accomplished by offering less costly, unduplicated alternatives when providing choices that adequately meet an individual's service needs. Those choices consist of all available services under these rules, the utilization of assistive devices, natural supports, home modifications, housing accommodations and alternative service resources not paid for by the Department. Cost effectiveness means that more than one service is not authorized to meet the same needs.

(18) "Department" means the Oregon Department of Human Services (ODHS).

(19) "Electronic Visit Verification (EVV)" means an interface that records the homecare worker's start time, end time, and geolocation for a service delivered by a homecare worker in real time.

(20) "Emergency Response Systems" mean a type of electronic back-up system that secures help for individuals in an emergency; ensures a consumer's safety in the community; and includes other reminders that help an individual with their activities of daily living and instrumental activities of daily living. This includes alert systems, units that are worn by the individual or are in the individual's home for the purpose of generating notification that an emergency has or may occur.

(21) "Evidence-Based Health Promotion" means individual or group programs that meet the requirements for the U.S. Administration on Community Living's Evidence-Based Definition or is an "evidence-based program" by any operating division of the U.S. Department of Health and Human Services (HHS) and is shown to be effective and appropriate for older adults.

(22) "Functional Impairment" means an individual's pattern of mental and physical limitations that restricts the individual's ability to perform activities of daily living and instrumental activities of daily living without the assistance of another person.

(23) "Health and Safety" means the essential actions necessary to meet an individual's health care, food, shelter, clothing, personal hygiene and other care needs without which serious physical injury or illness is likely to occur that would result in hospitalization, death or permanent disability.

(24) "Home" or "In-Home" means a setting that exhibits the characteristics described in OAR 411-030-0033(2)(a) - (d).

(25) "Home Delivered Meals" for the purpose of these rules means meals that are delivered by a home delivered meals provider with a Medicaid provider number to an eligible participant in their own home or apartment and meeting the criteria in OAR 411-040-0035.

(26) "Home Modifications" mean the changes made to adapt living spaces to meet specific service needs of eligible individuals with physical limitations to maintain their health, safety, and independence.

(27) "Homecare Worker" means a provider, as described in OAR 411-031-0040 (Consumer-Employed Provider Program), that is directly employed by an individual to provide hourly services to the eligible individual. The term homecare worker does not include an employee of an in-home care agency who is providing in-home services.

(28) "Household" means a group of individuals that live together within the same dwelling. For homeless individuals, the household consists of the individuals who consider themselves living together.

(29) "In-Home Care Agency" or "IHCA" means an agency as defined in OAR 333-536-0005 (Definitions) that is primarily engaged in providing in-home care services for compensation to an individual in that individual's place of residence. "In-home care agency" does not include a home health agency or portion of an agency providing home health services.

(30) "In-Home Support and Personal Care Services" mean those services that meet an individual's assessed need related to activities of daily living and instrumental activities of daily living provided in the individual's home or family's home.

(31) "Individual" means an older adult or an adult with a disability applying for or eligible for services. The term "individual" is synonymous with "consumer" or "client".

(32) "Informed choices" or "Informed decisions" means the individual is independent in decision making as defined in OAR 411-015-0006(3)(f)(B) or has the assistance of a representative to assist them in decision making.

(33) "Instrumental Activities of Daily Living (IADL)" means those activities, other than activities of daily living, required by an individual to continue independent living. The definitions and parameters for assessing needs in IADL are identified in OAR 411-015-0007.

(34) "Long Term Care Community Nursing Services" mean a distinct set of services that focus on an individual's chronic and ongoing health and activity of daily living needs. Long term care community nursing services include an assessment, monitoring, delegation, teaching, and coordination of services that addresses an individual's health and safety needs in a Nursing Service Plan that supports individual choice and autonomy. The requirements in these rules are provided in addition to any nursing related requirements stipulated in the licensing rules governing the individual's place of residence.

(35) "Natural Supports" or "Natural Support System" means resources and supports (e.g., relatives, friends, significant others, neighbors, roommates, or the community) who are willing to voluntarily provide services to an individual without the expectation of compensation. Natural Supports are identified in collaboration with the individual and the potential natural support. The Natural Support is required to have the skills, knowledge and ability to provide the needed services and supports.

(36) "Older Adult" means any person at least 60 years of age.

(37) "Oregon Project Independence- Medicaid (OPI-M)" means the services approved and funded by the Centers for Medicare and Medicaid Services (CMS) for eligible individuals in accordance with the 1115 demonstration waiver for the Oregon Project Independence-Medicaid program and including the services defined in these rules.

(38) "Person-centered service planning" means a process for selecting and organizing the services and supports with an eligible individual which includes the personal preferences and choices of the individual.

(39) "Representative" is the person appointed by the individual or a person with longstanding involvement in assuring the individual's health, safety and welfare. For the purposes of these rules, representative also includes legal representatives and designated representatives.

(40) "Service Priority Level (SPL)" means the order in which Department and AAA Type B transfer staff identify individuals eligible for a nursing facility level of care, Oregon Project Independence, Oregon Project Independence-Medicaid or Medicaid home and community-based services in OAR 411-015-0010. A lower SPL number indicates greater or more severe functional impairment. The number is synonymous with the SPL.

(41) "Services Case Manager" means an employee of a AAA or the Department who is providing OPI-M conflict-free case management. The Services Case Manager provides person-centered service planning for and with eligible individuals. This includes authorizing and implementing an individual's service plan and monitoring service provision as described in OAR chapter 411, division 016.

(42) "Supports for Consumer Direction" means activities to empower, train and inform individuals receiving in-home services regarding their rights, roles and responsibilities as employers of homecare workers, to empower the consumer to advocate for themselves in services and resources outside their service plan, such as health care and behavioral health services, housing, and transportation, and to help consumers manage their person-centered service plan, their personal goals and life experiences, ensuring the consumer's health, safety, and overall wellbeing.

(43) "Title XIX Medicaid" means a joint federal and state funded program for medical assistance established by Title XIX of the Social Security Act as amended and administered in Oregon

(44) "These Rules" means the rules in OAR chapter 411, division 016.

(45) "Unpaid Caregiver" means a caregiver that meets the criteria in OAR 411-016-0130(1).

Or. Admin. Code § 411-016-0005

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

Statutory/Other Authority: ORS 410.070

Statutes/Other Implemented: ORS 410.060, 410.070 & 414.065