Or. Admin. Code § 411-049-0145

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

Section 411-049-0145 - Medicaid Provider Enrollment Agreement (PEA)

(1) An applicant or licensee who intends to care for residents who are or become eligible for Medicaid services must enter into a Medicaid PEA with the Department, follow Department rules, and abide by the terms of the Medicaid PEA.

(2) An approved Medicaid PEA does not guarantee the placement of individuals eligible for Medicaid services in the AFH.

(3) An approved Medicaid PEA is valid for the length of the license unless earlier terminated by the licensee or the Department. A Medicaid PEA must be completed, submitted, approved, and renewed with each licensing cycle.

(4) The rate of compensation established by the Department is considered payment in full. The licensee may not request or accept additional funds or in-kind payment from any source.

(5) An individual eligible for Medicaid services may not be admitted into an AFH unless and until:

(a) The Department has approved a Medicaid PEA. The Department shall not issue a Medicaid payment to a licensee without a current license and an approved Medicaid PEA in place;

(b) The individual eligible for Medicaid services has been screened according to OAR 411-051-0110; and

(c) The Department has authorized the placement. The authorization must be clearly documented in the resident's record with other required admission materials. (See OAR 411-050-0750).

(6) The Department shall not make payment for the date a resident moves from the home, or for any time period thereafter.

(7) A licensee who elects to provide care for individuals eligible for Medicaid services is not required to admit more than one resident eligible for Medicaid services. However, if the licensee has an approved Medicaid PEA, private-pay residents who become eligible for Medicaid services may not be asked to leave solely based on Medicaid eligibility.

(8) The licensee or the Department may terminate a Medicaid PEA according to the terms of the Medicaid PEA.

(9) The Department may terminate a Medicaid PEA under the following circumstances:

(a) The licensee fails to maintain substantial compliance with all related federal, state, and local laws, ordinances, and regulations; or

(b) The license to operate the AFH has been voluntarily surrendered, revoked, or non-renewed.

(10) The Department must terminate a Medicaid PEA under the following circumstances:

(a) The licensee fails to permit access by the Department, the LLA, OHA, or CMS to any AFH licensed to and operated by the licensee.

(b) The licensee submits false or inaccurate information.

(c) Any person with five percent or greater direct or indirect ownership interest in the AFH did not submit timely and accurate information on the Medicaid PEA form or fails to submit fingerprints if required under the Background Check Rules in OAR 407-007-0200 to 407-007-0370.

(d) Any person with five percent or greater direct or indirect ownership interest in the AFH has been convicted of a criminal offense related to the person's involvement with Medicare, Medicaid, or Title XXI programs in the last 10 years.

(e) Any person with an ownership or control interest, or who is an agent or managing employee of the AFH, fails to submit timely and accurate information on the Medicaid PEA form.

(11) If the licensee submits notice of termination of the Medicaid PEA, the licensee must comply with the following requirements:

(a) Simultaneously issue the Department's Notice of Involuntary Move or Transfer of Resident form (APD 0901) to each resident eligible for Medicaid services in the licensee's AFH (See OAR 411-050-0760).

(b) Update Residency Agreement according to OAR 411-050-0705 and submit to the LLA for review.

(c) Obtain signatures of all current residents, or the resident's representative on the updated Residency Agreement following the LLA's review.

(12) If either the licensee or the Department terminates a Medicaid PEA, a new Medicaid PEA shall not be approved by the LLA for a period of not less than 180 days from the date the licensee or the Department terminated the Medicaid PEA.

(13) DEATH OF RESIDENT ELIGIBLE FOR MEDICAID SERVICES WITH NO SURVIVING SPOUSE. The licensee must forward all personal incidental funds (PIF) to the Estate Administration Unit, P. O. Box 14021, Salem, Oregon 97309-5024, within 10 business days of the death of a resident eligible for Medicaid services with no surviving spouse. (See Limits on Estate Claims, OAR 461-135-0835).

Or. Admin. Code § 411-049-0145

APD 19-2019, adopt filed 06/20/2019, effective 7/1/2019; APD 48-2022, minor correction filed 09/26/2022, effective 9/26/2022

Statutory/Other Authority: ORS 409.050, 410.070, 413.085, 443.001, 443.004, 443.725, 443.730, 443.735, 443.738, 443.742, 443.760, 443.767, 443.775, 443.880 & 443.790

Statutes/Other Implemented: ORS 409.050, 410.070, 413.085, 443.001 - 443.004, 443.705 - 443.825, 443.875 & 443.991