Or. Admin. Code § 411-048-0170

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

Section 411-048-0170 - Eligibility and Limitations

(1) ELIGIBILITY. Long term care community nursing services may be provided by an RN to an individual if the individual meets the following requirements:

(a) The individual must be determined eligible for Medicaid-funded home and community-based services provided through the Department.

(b) The individual must be receiving services through one of the following:

(A) A child who lives in the family home and receives children's intensive in-home services as described in OAR chapter 411, division 300.

(B) An adult foster home for:

(i) Individuals with intellectual or developmental disabilities as described in OAR chapter 411, division 360; or

(ii) Individuals found eligible for service in OAR chapter 411, division 015 residing in a Medicaid enrolled adult foster home as described in OAR chapter 411, divisions 049 through 052.

(C) A foster home for children with intellectual or developmental disabilities as described in OAR chapter 411, division 346.

(D) An adult or child who live in their own or family home as described in OAR chapter 411, division 030 or division 450.

(E) Independent Choices Program participants as described in OAR chapter 411, division 030.

(F) State Plan personal care participants as described in OAR chapter 411, division 034 or division 455.

(G) An adult who is eligible to receive day support activities as described in OAR chapter 411, division 450 or eligible to receive employment services as described in OAR chapter 411, division 345.

(H) Long term care community nursing services may be provided for individuals while receiving services in settings for employment services or day support activities regardless of their residential home and community-based setting.

(c) The individual must be referred by their case manager for long term care community nursing services. Individuals may request long term care community nursing services through their case manager.

(2) LIMITATIONS.

(a) Long term care community nursing services may not be provided to:

(A) A resident of a nursing facility, assisted living facility, or residential care facility.

(B) An individual residing in a setting where nursing services are already provided and paid as part of a contract or agreement with the Department. The Department will not issue duplicate or unbundled payments for nursing services.

(b) Case managers may not prior authorize long term care community nursing services that duplicate nursing services provided by Medicare or other Medicaid programs.

(c) Long term care community nursing services do not include nursing activities used for administrative functions such as protective service investigations, pre-admission screenings, eligibility determinations, licensing inspections, case manager assessments, or corrective action activities. This limitation does not include authorized care coordination as defined in OAR 411-048-0160.

(d) Long term care community nursing services do not include reimbursement for direct hands-on nursing as defined in OAR 411-048-0160.

(3) EXCEPTIONS. An exception to sections (2)(c) and (2)(d) of this rule may be requested as described in OAR 411-048-0250.

Or. Admin. Code § 411-048-0170

SPD 8-2013, f. & cert. ef. 4-15-13; SPD 14-2013(Temp), f. & cert. ef. 7-1-13 thru 12-28-13; SPD 44-2013, f. 12-13-13, cert. ef. 12-15-13; APD 12-2014(Temp), f. & cert. ef. 5-1-14 thru 10-28-14; APD 34-2014, f. & cert. ef. 10-1-14; APD 10-2021, temporary amend filed 02/24/2021, effective 03/01/2021 through 08/27/2021; APD 30-2021, amend filed 08/25/2021, effective 8/25/2021; APD 18-2023, amend filed 10/13/2023, effective 11/1/2023

Statutory/Other Authority: ORS 409.050 & 410.070

Statutes/Other Implemented: ORS 409.010 & 410.070