Or. Admin. Code § 411-030-0040

Current through Register Vol. 63, No. 11, November 1, 2024

Section 411-030-0040 - Eligibility Criteria

(1) In-home services are provided to individuals who meet the established priorities for service as described in OAR chapter 411, division 015 who have been assessed to be in need of in-home services. Payments for in-home services are not intended to replace the resources available to an individual from the individual's natural supports.

(2) An individual receiving Medicaid in-home services must:

(a) Meet the established priorities for service as described in OAR chapter 411, division 015.

(b) Meet all the eligibility requirements in OAR 411-015-0010 through 411-015-0100

(c) Reside in a living arrangement described in OAR 411-030-0033.

(3) An individual receiving services through the Independent Choices Program must:

(a) Meet the established priorities for service as described in OAR chapter 411, division 015.

(b) Be a current recipient of OSIPM (Oregon Supplemental Income Program Medical).

(c) Reside in a living arrangement described in OAR 411-030-0033.

(d) Be 18 years of age or older.

(4) CONSUMER-EMPLOYER RESPONSIBILITIES.

(a) To be eligible for in-home services provided by a homecare worker, an individual must be able to, or designate a representative to:

(A) Locate, screen, and hire a qualified homecare worker;

(B) Supervise and train the homecare worker;

(C) Schedule the homecare worker's work, leave, and coverage;

(D) Track the hours worked and verify the authorized hours completed by the homecare worker;

(E) Recognize, discuss, and attempt to correct any performance deficiencies with the homecare worker;

(F) Discharge an unsatisfactory homecare worker; and

(G) Follow all employer responsibilities required by law to ensure the workplace is safe from harassment.

(b) The Department may require individuals who have failed to meet the responsibilities in subsection (a) of this section to designate a representative to exercise these responsibilities. A representative of an individual may not be a homecare worker providing homecare worker services to the individual.

(A) Individuals who have failed to meet the responsibilities in subsection (a) of this section and who does not have a representative are ineligible for in-home services provided by a homecare worker.

(B) Individuals must also be offered other available community-based service options to meet the individual's service needs, including contracted in-home care agency services, nursing facility services, or other community-based service options.

(c) An individual determined ineligible for in-home services provided by a homecare worker and who does not have a representative may request in-home services provided by a homecare worker at the individual's next re-assessment, but no sooner than 12 months from the date the individual was determined ineligible.

(A) To reestablish eligibility for in-home services provided by a homecare worker, an individual must attend training and acquire, or otherwise demonstrate, the ability to meet the employer responsibilities in subsection (a) of this section. Improvements in health and cognitive functioning, for example, may be factors in demonstrating the individual's ability to meet the employer responsibilities in subsection (a) of this section.

(B) If the Department determines an individual may not meet the individual's employer responsibilities, the Department may require the individual appoint an acceptable representative.

(d) The Department retains the right to approve the representative selected by an individual. Approval may be based on, but is not limited to, the representative's criminal history, protective services history, or credible allegations of fraud or collusion in fraudulent activities involving a public assistance program.

(e) If an individual's designated representative is unable to meet the employer responsibilities of subsection (a) of this section, or the Department does not approve the representative, the individual must designate a different representative or select other available services.

(f) An individual with a history of credible allegations of fraud or collusion in fraud with respect to in-home services is not eligible for in-home services provided by a homecare worker or by a personal support worker under the Independent Choices Program.

(5) REPRESENTATIVE.

(a) The Department may require that an individual obtain a representative to act as the consumer-employer or for service planning purposes.

(b) The Department, or the Department's designee, may deny an individual's request for any representative if the representative has a history of a substantiated adult protective service complaint as described in OAR chapter 411, division 020. The individual may select another representative.

(c) An individual with a guardian must have a representative to act as the consumer-employer and for service planning purposes. A guardian may designate themselves as the representative.

(d) A representative may not be a paid caregiver for the individual they are representing.

(6) Additional eligibility criteria for Medicaid in-home services exist for individuals eligible for:

(a) The Consumer-Employed Provider Program as described in OAR chapter 411, division 031;

(b) The Independent Choices Program as described in OAR 411-030-0100 of these rules; and

(c) The Spousal Pay Program as described in OAR 411-030-0080 of these rules.

(7) Individuals living in any of the following settings are not eligible for in-home services:

(a) A licensed community-based care facility, including an adult foster home;

(b) A nursing facility;

(c) Prison;

(d) A hospital; or

(e) Any other institution or facility that provide assistance with ADLs or other services.

(8) Individuals with excess income must contribute to the cost of service pursuant to OAR 461-160-0610 and OAR 461-160-0620.

Or. Admin. Code § 411-030-0040

SSD 3-1985, f. & ef. 4-1-85; SSD 4-1993, f. 4-30-93, cert. ef. 6-12-93, Renumbered from 411-030-0001; SPD 2-2003(Temp), f. 1-31-03, cert. ef. 2-1-03 thru 7-30-03; SPD 14-2003, f. & cert. ef. 7-31-03; SPD 15-2003 f. & cert. ef. 9-30-03; SPD 18-2003(Temp), f. & cert. ef. 12-11-03 thru 6-7-04; SPD 15-2004, f. 5-28-04, cert. ef. 6-7-04; SPD 18-2005(Temp), f. 12-20-05, cert. ef. 12-21-05 thru 6-1-06; SPD 1-2006(Temp), f. & cert. ef. 1-13-06 thru 6-1-06; SPD 20-2006, f. 5-26-06, cert. ef. 6-1-06; SPD 4-2008(Temp), f. & cert. ef. 4-1-08 thru 9-24-08; SPD 13-2008, f. & cert. ef. 9-24-08; SPD 15-2008, f. 12-26-08, cert. ef. 1-1-09; SPD 10-2013(Temp), f. & cert. ef. 5-23-13 thru 11-19-13; SPD 43-2013, f. 10-31-13, cert. ef. 11-1-13; APD 9-2014(Temp), f. 4-17-14, cert. ef. 4-21-14 thru 10-18-14; APD 35-2014, f. & cert. ef. 10-1-14; APD 49-2014(Temp), f. 12-30-14, cert. ef. 1-1-15 thru 6-29-15; APD 9-2015, f. 3-30-15, cert. ef. 4/3/2015; APD 21-2017, temporary amend filed 09/29/2017, effective 10/01/2017 through 01/27/2018; APD 3-2018, amend filed 01/27/2018, effective 1/28/2018; APD 11-2018, temporary amend filed 05/23/2018, effective 05/23/2018 through 11/18/2018; APD 40-2018, amend filed 11/15/2018, effective 11/18/2018; APD 32-2020, amend filed 07/23/2020, effective 8/1/2020

Statutory/Other Authority: ORS 409.050, 410.070 & 410.090

Statutes/Other Implemented: ORS 410.010, 410.020 & 410.070