Department of Human Services, Aging and People with Disabilities 411

Transcription

1 Secretary of State NOTICE OF PROPOSED RULEMAKING HEARING* A Statement of Need and Fiscal Impact accompanies this form. Department of Human Services, Aging and People with Disabilities 411 Agency and Division Administrative Rules Chapter Number Kimberly Colkitt-Hallman 500 Summer Street NE, E-48 (503) Salem, OR Rules Coordinator Address Telephone RULE CAPTION Eligibility for Medicaid K-State Plan in Long-Term Care Service Priorities; K-State Plan; and In-Home Services Not more than 15 words that reasonably identifies the subject matter of the agency s intended action. March 17, :00 pm Human Services Building Staff 500 Summer Street NE, ROOM 160 Salem, Oregon Hearing Date Time Location Hearings Officer Auxiliary aids for persons with disabilities are available upon advance request. RULEMAKING ACTION Secure approval of new rule numbers (Adopted or Renumbered rules) with the Administrative Rules Unit prior to filing. ADOPT: AMEND: , , , , , , , REPEAL: (T), (T), (T), (T), (T), (T), (T), (T) RENUMBER: AMEND & RENUMBER: Stat. Auth.: ORS Other Auth.: Stats. Implemented: ORS

2 RULE SUMMARY The Department of Human Services (Department) is proposing to amend the rules in OAR , 030, and 035 to make permanent changes from the January 1, 2015 temporary rulemaking, which puts the Department in compliance with mandates from the Center for Medicare and Medicaid Services (CMS). CMS requires that individuals applying for Medicaid State Plan K-option with an underlying Medicaid OHP Plus benefit package under through the Medicaid for Modified Adjusted Gross Income (MAGI) are eligible only if certain other eligibility criteria are met, including the equity value of an individual s home as established in OAR These individuals are subject to requirements of OAR regarding the equity value of the home in the same manner as if they were requesting these services under OSIPM. This criteria was added to the rules as it was not in them prior to the temporary rulemaking. As part of this amendment, stronger language was added to emphasize requirements of the rules for transfer of assets to be applied in the same manner as if they were requesting these services under OSIPM. The wording requirements of the rules is then consistent with the rule pertaining to the equity value of the home. The in-home service rules in division 030 and K-Plan division 035 are required to use all the eligibility criteria as the rules, as well as eligibility criteria specific to each of the program rules in divisions 030 and 035. This means all mutual eligibility criteria were tied back to the eligibility criteria. Minor punctuation, grammar, and formatting changes were made to the rules as well. The Agency requests public comment on whether other options should be considered for achieving the rule s substantive goals while reducing the negative economic impact of the rule on business. Written comments may be submitted via to Kimberly.Colkitt-Hallman@state.or.us or mailed to 500 Summer Street NE, E48 Salem, Oregon, All comments received will be given equal consideration before the Department proceeds with the permanent rulemaking. March 21, 2015 at 5 p.m. Last Day for Public Comment (Last day to submit written comments to the Rules Coordinator) Signed Michael R. McCormick, Director, Aging and People with Disabilities 2/6/2015 Signature Date

3 Secretary of State A Notice of Proposed Rulemaking Hearing or a Notice of Proposed Rulemaking accompanies this form. Department of Human Services, Aging and People with Disabilities 411 Agency and Division Administrative Rules Chapter Number Eligibility for Medicaid K-State Plan in Long-Term Care Service Priorities; K-State Plan; and In-Home Services Rule Caption (Not more than 15 words that reasonably identifies the subject matter of the agency s intended action.) In the Matter of: The amendment of OAR , , , , , , , and and repeal of temporary rules (T), (T), (T), (T), (T), (T), (T), and (T) relating to long-term care service eligibility criteria. Statutory Authority: ORS Other Authority: Stats. Implemented: ORS Need for the Rule(s): The Department needs to amend the rules in OAR , 030, and 035 to be in compliance with the Center for Medicare and Medicaid Services (CMS). CMS mandates that individuals applying for State Plan K-option services with an underlying Medicaid OHP Plus eligibility under through the Medicaid for Modified Adjusted Gross Income (MAGI) are eligible only if certain other eligibility requirements are met and the equity value of an individual s home does not to exceed the limits set forth in OAR Prior to the amendments, Medicaid for Modified Adjusted Gross Income (MAGI) OHP Plus medical benefit eligibility in the rule did not have any limitation on the individual s resources or the home equity value of their home, which would not comply with CMS. The Department will remain compliant with CMS by making permanent temporary rule language from January 1, 2015 that makes these individuals subject to the requirements of OAR regarding the equity value of the home in the same manner as if they were requesting these services under OSIPM. For emphasis and consistency, stronger language was also added for the requirements of the rules for transfer of assets section of this rule as well. The in-home service rules in division 030 and K-Plan division 035 are required to use all the eligibility criteria as the rules, as well as eligibility criteria specific to each of the program rules in divisions 030 and 035. These rule amendments accomplish this by pointing all mutual eligibility criteria to the eligibility criteria.

4 Minor punctuation, grammar, and formatting issues in the rules were addressed as well. Documents Relied Upon, and where they are available: Fiscal and Economic Impact: The Department does not expect a fiscal impact due to the small number of individuals that may be affected. Statement of Cost of Compliance: 1. Impact on state agencies, units of local government and the public (ORS (2)(b)(E)): The Department is unable to determine a fiscal impact at this time as data is not yet available for the number of individuals receiving OHP Plus benefits through the Medicaid Modified Adjusted Gross Income (MAGI) Program. Even though enough data is not yet available for individuals receiving MAGI benefits, all individuals receiving Medicaid nursing facility and home and community based care (CBC) services will be subject to the requirements of OAR regarding the equity value of the home in the same manner as if they were requesting these services under OSIPM. Medicaid for Modified Adjusted Gross Income (MAGI) OHP Plus medical benefit eligibility does not have any limitation on the individual s resources or the home equity value of their home. It is expected that some MAGI eligible individuals may be impacted by this rule and will not be eligible to receive Medicaid nursing facility and home and CBC services, as their home equity value may exceed the limitations set forth in OAR However the number of individuals impacted by this limitation is anticipated to be very small, as the equity value of an individual s home is excluded unless the value is more than the current limitation of $552,000. State Agencies: The Department estimates there will be no fiscal or economic impact on other state agencies. Units of Local Government: The Department estimates there will be no fiscal or economic impact on units of local government. Consumers: The Department estimates there will be minimal impact on MAGI eligible individuals receiving services, as it is unlikely that many individual s home equity value will exceed the current limitation of $552,000. Providers: The Department estimates there will be little or no fiscal impact on providers. Public: The Department estimates there will be no fiscal or economic impact on the public. 2. Cost of compliance effect on small business (ORS ): a. Estimate the number of small businesses and types of business and industries with small businesses subject to the rule:

5 These rule revisions do not have a direct fiscal impact on small businesses. However, representatives for small businesses were invited to the Rule Advisory Committee (RAC). The proposed rules do not impact small businesses as defined by ORS Projected reporting, recordkeeping and other administrative activities required for compliance, including costs of professional services: The proposed changes will not impact reporting, recordkeeping, or administrative activities as described above in the Department's statement of cost of compliance. c. Equipment, supplies, labor and increased administration required for compliance: The proposed changes will not impact equipment, supplies, labor or increased administration costs as described above in the Department's statement of cost of compliance. How were small businesses involved in the development of this rule? A small business as defined in ORS participated on the Administrative Rule Advisory Committee. Small businesses will also be included in the public review and comment period. Administrative Rule Advisory Committee consulted?: Yes. The Administrative Rule Advisory Committee (RAC) included representation from the Long Term Care (LTC) Ombudsman, American Association of Retired Persons (AARP), Legal Aid, Oregon Law Center, Oregon Healthcare Association, Disability Rights Oregon, SEIU, Leading Age Oregon, Medicaid LTC Quality Reimbursement Advisory Council (MLTQRAC), Alzheimer s Association, Homecare Commission, Oregon Association of Area Agencies on Aging & Disabilities, Oregon Disabilities Commission, State Independent Living Council, and representatives from small businesses were invited. The RAC was done electronic through , rather than inperson. All RAC members agreed to attend electronically and did not request in-person attendance. Signed Michael R. McCormick, Director, Aging and People with Disabilities 2/6/2015 Signature Date

6 DEPARTMENT OF HUMAN SERVICES AGING AND PEOPLE WITH DISABILITIES OREGON ADMINISTRATIVE RULES CHAPTER 411 DIVISION 15 LONG-TERM CARE SERVICE PRIORITIES FOR INDIVIDUALS SERVED Eligibility for Nursing Facility or Medicaid Home and Community-Based Services (1) To be eligible for nursing facility services or Medicaid home and community-based services, a person must: (a) Be age 18 or older. (b) Be eligible for the Medicaid OHP Plus benefit package. (A) An individualindividuals receiving Medicaid OHP Plus under OAR coverage for services in a nonstandard living arrangement as defined in(see OAR ) is are subject to the requirements the rules regarding transfer of assets (see OAR to ) in the same manner as if they were requesting these services under OSIPM, including the rules regarding:. This includes, but is not limited to, the following assets: (i) The transfer of assets as set forth in OAR to ; and (ii) The equity value of a home which exceeds the limits as set forth in OAR (i) An annuity is evaluated according to OAR ; (ii) A transfer of property when an individual retains a life estate is evaluated according to OAR ; Page 1 of 14

7 (iii) A loan made by an individual is evaluated according to OAR ; (iv) An Iirrevocable trust is evaluated according to OAR ; (B) When an individual is disqualified for a transfer of assets, a notice for transfer of assets is required in accordance with OAR (C) When an individual is determined ineligible for the equity value of a home, a notice for being over resources is required in accordance with (c) Meet the functional impairment level within the service priority levels currently served by the Department as outlined in OAR and the requirements in OAR (2) To be eligible for services paid through the Spousal Pay Program, an individual must meet the requirements listed above in section (1) of this rule in addition to the requirements in OAR (3) Individuals who are age 17 or younger and reside in a nursing facility, are eligible for nursing facility services only and are not eligible to receive Medicaid home and community-based services administered by the Department's Aging and People with Disabilities. Stat. Auth.: ORS Stats. Implemented: ORS , , & Page 2 of 14

8 DEPARTMENT OF HUMAN SERVICES AGING AND PEOPLE WITH DISABILITIES OREGON ADMINISTRATIVE RULES Eligibility Criteria CHAPTER 411 DIVISION 30 IN-HOME SERVICES (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. (a) Payments for in-home services are not intended to replace the resources available to an individual from the individual's natural supports. (b) An individual whose service needs are sufficiently and appropriately met by available natural supports is not eligible for inhome services. (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 through ; and Be a current recipient of a Medicaid OHP Plus benefit package. Recipients receiving Medicaid OHP Plus benefits are subject to the transfer of assets rule criteria described in section (1)(b) of OAR ; (c) Reside in a living arrangement described in OAR ; and (d) Be 18 years of age or older. Page 3 of 14

9 (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 ; and (d) Be 18 years of age or older. (4) To be eligible for Medicaid in-home services, an individual must employ an enrolled homecare worker or contracted in-home care agency. To be eligible for the ICP, a participant must employ an employee provider. (5) Initial eligibility for Medicaid in-home services, or the ICP, does not begin until an individual's service plan has been authorized by the Department or the Department s designee. The service plan must identify the provider who delivers the authorized services, include the date when the provision of services begins, and include the maximum number of hours authorized. Service plans must be based upon the least costly means of providing adequate services. (6) If, for any reason, the employment relationship between an individual and provider is discontinued, an enrolled homecare worker or contracted in-home care agency must be employed within 14 business days for the individual to remain eligible for in-home services. A participant of the ICP must employ an employee provider within 14 business days to remain eligible for ICP services. The individual s case manager has the authority to waive the 14 business day restriction if the individual is making progress towards employing a provider. (7) An eligible individual who has been receiving in-home services who temporarily enters a nursing facility or medical institution must employ an enrolled homecare worker or contracted in-home care agency within 14 business days of discharge from the facility or institution for the individual to remain eligible for in-home services. A participant of the ICP must employ Page 4 of 14

10 an employee provider within 14 business days of discharge to remain eligible for ICP services. (8) EMPLOYER RESPONSIBILITIES. (a) In order 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; and (F) Discharge an unsatisfactory homecare worker. (b) Individuals who are unable to meet the responsibilities in subsection (a) of this section are ineligible for in-home services provided by a homecare worker. Except as set forth in subsection (f) of this section, individuals ineligible for in-home services provided by a homecare worker may designate a representative to manage the individual s responsibilities as an employer on the individual s behalf. A representative of an individual may not be a homecare worker providing homecare worker services to the individual. 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 Page 5 of 14

11 individual's next re-assessment, but no sooner than 12 months from the date the individual was determined ineligible. 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. 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. (9) REPRESENTATIVE. (a) 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. (b) An individual with a guardian must have a representative for service planning purposes. A guardian may designate themselves as the representative. Page 6 of 14

12 (10) 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 of these rules; and (c) The Spousal Pay Program as described in OAR of these rules. (11) Residents of licensed community-based care facilities, nursing facilities, prisons, hospitals, and other institutions that provide assistance with ADLs, are not eligible for in-home services. (12) Individuals with excess income must contribute to the cost of service pursuant to OAR and OAR Stat. Auth.: ORS , , & Stats. Implemented: ORS , , & Page 7 of 14

13 DEPARTMENT OF HUMAN SERVICES AGING AND PEOPLE WITH DISABILITIES OREGON ADMINISTRATIVE RULES CHAPTER 411 DIVISION 35 K-State Plan Eligibility for Supplemental K State Plan Services To be eligible for any Medicaid Supplemental K State Plan services defined in this division, consumers must: (1) Be eligible for Medicaid long term care services and supports as described in OAR through (2) Not have natural supports or other services available in the community that would meet the identified need. (3) Not be eligible for the item through Medicare, other Medicaid programs, or other medical coverage. (4) Have an identified need in their person-centered service plan that: (a) Supports the desires and goals of the consumer receiving services and increases a consumer's independence; (b) Reduces a consumer's need for assistance from another person; or (c) Maintains a consumer's health and safety. (5) Be provided the choice to accept or deny the service being offered. Stat. Auth.: ORS Stats. Implemented: ORS , , , to , Page 8 of 14

14 Eligibility for Consumer Electronic Back-up Systems and Assistive Technology (1) To be eligible for electronic back-up systems or mechanisms, a consumer must: not be receiving community-based care in a licensed care setting. (a) Meet all Medicaid eligibility criteria described in OAR ; and (b) Not be receiving community-based care in a licensed care setting. (2) Electronic back-up systems and assistive technologies must be appropriate and cost effective to meet the service needs of the consumer and: (a) For new equipment: (A) Are limited to a maximum of $5000 for purchasing of a device. (B) Monthly rentals or lease fee limits are posted on the APD rate table. (b) For repairs: (A) Repair of purchased devices may be done if the repair is more cost effective than purchasing a new device. (B) Repairs of rented or leased equipment are the responsibility of the provider. (c) Monthly maintenance, fees, or service charges are not included in the maximums described in (a) or (b). (3) Exceptions to the $5000 limitation may be granted if the consumer has service needs that warrant an exception for payment and no alternative is available to meet the needs of the consumer. Page 9 of 14

15 (4) Expenditures over $500 must be approved by the Department. Stat. Auth.: ORS Stats. Implemented: ORS , , , to , Eligibility Criteria for Chore Services (1) To be eligible for chore services, a consumer must meet all Medicaid Long Term Care eligibility requirements described in OAR not be receiving community-based care in a licensed care setting. (2) An eligible consumer may receive chore services under any of the following circumstances: (a) The consumer is the owner, buyer, or renter of the premises in which the consumer lives. (A) If a renter, the consumer must have received an eviction notice, written warning, or deficiency notice from the landlord or a public housing agency related to cleanliness or health issues of the unit; or (B) If an owner or buyer, the consumer must have received a written notice from a government agency or a lender concerning health, safety, or public nuisance deficiencies or violations. (b) The consumer needs garbage pick-up and removal, or payment of previous garbage bills, in order to continue or resume receiving services to ensure the home is safe for the consumer and their service providers. (c) The consumer s premises requires heavy cleaning to remove hazardous debris or dirt in the home to ensure the consumer s home is safe and allows for independent living. Page 10 of 14

16 (d) The consumer's premises require the removal of outside debris (for example, trees, leaves, clutter) which is endangering the structure of the home or the ability of the consumer to enter or exit safely. (e) The services must be completed to enable the consumer to move from one residence to another and to establish services in the new home. (3) If the service is done in a rental location, the service must be a service that is not required of the landlord under applicable landlord-tenant law. (4) Chore services are not part of the consumer s on-going service plan. Once the chore service is complete, homecare workers may begin or continue ongoing housekeeping. (5) Chore services must be appropriate and cost effective to meet the service need of the consumer. (a) If feasible, three bids are required from companies or vendors who provide chore services. A bid is not comparative pricing through the Internet. (b) Bids over $ require a state licensed contractor. (6) The consumer must sign a written agreement to: (a) Have a vendor clean their home; (b) Remove hazardous debris; or (c) To haul off agreed upon items that may pose a health and safety risk to the consumer or others. Stat. Auth.: ORS Stats. Implemented: ORS , , , to , Eligibility for Consumer Environmental Modifications Page 11 of 14

17 (1) To be eligible for environmental modifications, a consumer must: not be receiving community-based care in a licensed care setting. (a) Meet all Medicaid eligibility criteria described in OAR (2) An eligible consumer may receive environmental modification under any of the following circumstances: (ab) The consumer is the owner, buyer, or renter of premises in which the consumer lives. Be eligible for Medicaid long-term care services and supports and live in their own home or a rental property. (bc) If in a rental location, the consumer must have a written and signed agreement between the consumer receiving services and the owner or landlord of the rental property. (A) The agreement must include: (i) The scope of work provided; (ii) That the modification is permissible; and (iii) That the Department shall not restore the rental unit to its former condition. (B) Environmental modifications in rental locations must not be for services that are required of the landlord under applicable landlord-tenant law. (32) Environmental modifications are not part of the consumer s on-going service plan. Once the environmental modification is complete, environmental modification services shall cease and a reduction notice must not be issued. (43) Environmental modifications must be appropriate, cost effective, and meet the service need of the consumer. Page 12 of 14

18 (a) Environmental modifications are limited to a maximum of $5000 per environmental modification. (b) If feasible, three bids are required from companies or vendors. A bid is not comparative pricing through the Internet. (54) Exceptions to the $5000 limitation may be granted if the consumer has service needs that warrant an exception for payment and no alternative is available to meet the needs of the consumer. Stat. Auth.: ORS Stats. Implemented: ORS , , , to , Eligibility for Consumer Transition Services (1) Eligibility for transition services covered through the K-State Plan are restricted to consumers transitioning from a nursing facility or the Oregon State Hospital, as defined in OAR (16), into a communitybased or in-home program., and who meet the level of care criteria described in OAR (2) Consumers transitioning from an acute care hospital directly to a community-based or in-home program are not eligible for transition services under this rule. Stat. Auth.: ORS Stats. Implemented: ORS , , , to , Consumer Eligibility Criteria for Voluntary Consumer Training Services (1) To be eligible for K-State Plan Voluntary Consumer Training Services, consumers must be or be expected to, receive services in a setting described in OAR , In-Home Service Living Arrangement. : (a) Be eligible for Medicaid long-term care services and supports as described in OAR through ; and Page 13 of 14

19 (b) Be, or be expected to, receive services in a setting described in OAR , In-Home Service Living Arrangement. (2) Services are voluntary in nature. (3) Services may be provided to designated representatives performing the duties of a consumer-employer on behalf of the consumer. (4) Natural supports and designated representatives may receive services in addition to the eligible consumer. (5) All in-home consumers participating in the Consumer-Employed Provider Program must be offered the voluntary training during the in-home service planning process. Case managers must make a referral to an approved training provider. Stat. Auth.: ORS Stats. Implemented: ORS , , , to , Page 14 of 14