Oregon Administrative Rules
Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES
Division 33 - IN-HOME CARE AGENCIES PROVIDING MEDICAID IN-HOME SERVICES
Section 411-033-0030 - Medicaid In-Home Care Agency Provider Enrollment, Requirements, and Payment
Universal Citation: OR Admin Rules 411-033-0030
Current through Register Vol. 63, No. 3, March 1, 2024
(1) PROVIDER ENROLLMENT.
(a) Application and Agreement. A
provider must be an enrolled Medicaid provider in order to be eligible to
receive payment from the Department for claims in connection with services
provided by an IHCA.
(b) The
criteria for provider enrollment includes, but is not limited to:
(A) Meeting all program-specific
requirements;
(B) Providing a copy
of the IHCA agency's current OHA Public Health issued comprehensive classified
license;
(C) Obtaining a Medicaid
Provider Number;
(D) Current
Business registration and assumed business name (DBA), if applicable, with the
Oregon Secretary of State's Corporations Division; and
(E) Completing a Medicaid Provider Enrollment
Agreement.
(2) Staffing Requirements. According to OAR 333-536-0070, the agency owner or administrator shall ensure the agency has qualified and trained employees sufficient in number to meet the needs of the clients receiving services 365 days per year, including holidays.
(3) On-site Monitoring and Assessment.
(a) The IHCA shall provide to DHS or the AAA
a quarterly summary report for each Medicaid individual, which includes
documentation of client needs and services delivered. These records must be
maintained by the IHCA to provide the records necessary to fully disclose the
extent of the services, care, and supplies furnished to
beneficiaries.
(b) The IHCA shall
provide a copy of all information and documents as requested by DHS or the AAA.
This requested information may include, but is not limited to:
(A) Individual records (OAR
333-536-0085).
(B) Individual
nursing services (OAR 333-536-0080).
(C) Quality improvement records (OAR
333-536-0090).
(D) Complaint
investigation findings (OAR 333-536-0043).
(E) Organization, administration, and
personnel records (OAR 333-536-0050).
(F) Individual surveys of services and
payments (OAR 333-536-0041).
(G)
The requested information shall be submitted to DHS or the AAA within five
business days of the request. However, if the requesting DHS or AAA office
indicates the request involves individual safety, well-being, or a protective
service investigation, the information must be submitted within 24 hours of the
request.
(c) The IHCA
shall cooperate with any DHS quality assurance visits regarding monitoring of
any provision of IHCA services.
(d)
The IHCA shall participate in individual conferences with DHS or AAA case
managers, as requested.
(4) Insurance Requirements. Insurance requirements are defined in the Provider Enrollment Agreement.
(5) Payment and Financial Reporting.
(a) The case manager shall authorize
reimbursement for the service hours identified in the individual's Medicaid
Management Information System (MMIS) plan of care.
(b) The IHCA shall comply with section
12006(a) of the 21st Century Cures Act by electronically verifying, with
respects to visits conducted as part of personal care services, the following:
(A) The type of service performed;
(B) The individual receiving the
service;
(C) The date of the
service;
(D) The location of the
service delivery;
(E) The
individual providing the service; and
(F) The time the service begins and
ends.
(c) The IHCA must
provide the department with a monthly report showing:
(A) The consumer(s) name.
(B) The consumer(s) Medicaid prime
number.
(C) The date service(s)
were provided.
(D) The location
service(s) were provided.
(E) The
start and end time of service(s) provided.
(F) The service(s) provided.
(d) The IHCA must use MMIS to
submit claims for reimbursement of Medicaid authorized services. All claims
must be submitted no later than 12 months from date of service.
(e) The IHCA shall be reimbursed --
(A) Only for services delivered to an
individual.
(B) Only at the
approved hourly rate for ADL and IADL services.
(C) For up to three hours at the ADL care
rate, for the required, completed initial assessment.
(D) For community transportation mileage
related to an assessed ADL or IADL need (e.g., shopping). Reimbursement for
community transportation may not include mileage for an employee commuting to
and from the individual's home. The IHCA employee must maintain valid driver's
license, current vehicle registration and necessary auto insurance, if
transporting the Medicaid individual. Proof must be available upon the request
of the Department.
(f)
IHCA's shall be reimbursed per the rates established in the rate schedule for
home and community-based services in OAR 411-027-0170.
Statutory/Other Authority: ORS 409.050, 410.070, 410.090 & 413.085
Statutes/Other Implemented: ORS 410.010, 410.020, 410.070 & 413.085
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