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Presentation on theme: "OARs for OPI FALL 2014 MARK ACUNA CHAPTER 411 DIV. 32."— Presentation transcript:


2 Eligibility for OPI 411-032-0020 (a) In order to qualify for authorized services from an AAA or service provider, each eligible individual must: (A) Be 60 years old or older or be under 60 years of age and diagnosed as having Alzheimer's Disease or a related disorder; (B) Not be receiving financial assistance or Medicaid, except food stamps, or Qualified Medicare Beneficiary or Supplemental Low Income Medicare Beneficiary Programs; and (C) Meet the requirements of the long-term care services priority rules in OAR chapter 411, division 015 (Long Term Care rules).

3 Goals of OPI 411-032-0001 (1) Promote quality of life and independent living among older adults and people with physical disabilities; (2) Provide preventive and long-term care services to eligible individuals to reduce the risk for institutionalization and promote self-determination; (3) Provide services to frail and vulnerable adults who are lacking or have limited access to other long-term care services; and (4) Optimize eligible individuals' personal resources and natural supports.

4 Priority for OPI Services 411-032- 0020(3) Priority for authorized services is: (A) Maintaining eligible individuals already receiving authorized service as long as their condition indicates the service is needed. (B) Individuals screened utilizing a Department authorized tool that measures risk for out of home placement based on an individual’s financial, physical, functional, medical, and social service needs. Individuals with the highest risk of out of home placement are given priority.

5 Eligibility for OPI & LTC Rules 411 Division 015  Require an In-Home Assessment 411-015-0008(f)  Failure to participate in an assessment 411-015-0008(j)(A)  Require Use of the CAPS assessment tool 411-015-0008(e)  Define the Service Priority Levels and require SPL 18 or below 411-015-0010 and 411-015-0015(1)(b)

6 Eligibility for OPI & LTC Rules 411-015-0015 rules state the following individuals are not eligible for services:  Individuals eligible for Developmental Disability Services. 411-015-0015(4) There are no provisions in the OAR’s for exceptions to this rule.

7 Eligibility for OPI & LTC Rules 411-015-0015 rules state the following individuals are not eligible for services:  Individuals with a diagnosis of a mental or emotional disorder. 411-015-0015(5)  Individuals with a substance abuse related disorder. 411-015-0015(5) For the above two populations there is an exception to the Rule as follows on the next slide.

8 Eligibility for OPI & LTC Rules 411-015-0015(5) Unless… (a) The individual has a medical non-psychiatric diagnosis or physical disability; (b) The individual's need for services is based on his or her medical, non- psychiatric diagnosis, or physical disability; and (c) The individual provides supporting documentation demonstrating that his or her need for services is based on the medical, non-psychiatric diagnosis, or physical disability. The Department authorizes documentation sources through approved and published policy transmittals.

9 Citizenship for OPI There is no citizenship requirement for eligibility in the OPI Rules. An applicant for the OPI Program does not have to provide any citizenship information. Non-citizen aliens, temporary residents, and those non-citizens on CAWEM are eligible to apply for OPI and need to meet the other OPI requirements.

10 Eligibility for OPI 411-032-0020 (d) Individuals residing in the following settings are not eligible for authorized services:  Nursing Facility  Assisted Living Facility  Residential Care Facility  Adult Foster Home This does not restrict the ability to move an eligible individual from such institutions to their home to receive authorized services, when judged more appropriate, based on medical, financial, physical, functional, and social considerations.

11 Duplication of Services 411-032-0020 (e) Any individual residing in a living setting that offers any services authorized under OAR 411-032-0010 is limited to receiving OPI authorized services that are not available in that setting.

12 Frequency of Service Assessments 411-032-0020 (2)(d) OPI Rules require a service assessment  At the initial eligibility determination.  At regular intervals, but not less than once every twelve months.

13 Hearing Rights for OPI OPI clients do NOT have a right to an Administrative Hearing. They DO have a right to an Administrative Review per OAR 411-032-0020(4) (c) if they are not satisfied with the results of the Grievance process. The AAA should make OPI clients aware of their right to an Administrative Review by the DHS, in the same letter that is sent to them with the grievance procedure.

14 Denial Notice for OPI Do not send an APD 540 Denial Notice since that is not an OPI form. There is no official denial notice for OPI, unless your AAA has instituted one per local policy. Case Managers should send a letter indicating the individual does not qualify for OPI (for SPL reasons, etc.). Include the grievance process in the letter.

15 Spousal Pay for OPI Payment to a spouse as a HCW is not possible with OPI. OPI rules require us to follow the Chapter 411 service rules. OAR 411-031-0020 (36) HCW CEP program rules define relatives as HCWs, and specifically exclude spouses. Spouses can only be paid in the Title XIX Spousal Pay program. That excludes spouses from being paid through the OPI program. In addition, payments for OPI in-home services are not intended to replace the resources available to an individual from the individual's natural supports, OAR 411-030-0040 (1)(a)

16 Medical Deductions for OPI OAR 411-032-0044 defines the deductions: 1) All out of pocket health care costs may be deducted. 2) All child support paid by a non-custodial parent may be deducted. Items that qualify include: Health insurance premiums (Medicare & supplements), medical bills (monthly payments), over the counter medicines (average for month), medical equipment payments or rental, out-of-pocket prescription drug co-pays (average for month), dental bills & dental appliances (monthly payments), medical treatments (PT & OT etc), herbal remedies recommended by a licensed health professional, medical supplies (catheters, test strips, etc) In-home nursing care, or payment for adult day care etc.

17 OPI Confidentiality 411-032-0015(4) CONFIDENTIALITY. The use or disclosure by any party of any information concerning a recipient of authorized services described in these rules, for any purpose not directly connected with the administration of the responsibilities of the Department, AAA, or service provider is prohibited except with written consent of the recipient, or their legal representative. Disclosure of recipient information must meet Department requirements.

18 Additional Helps

19 CAPS Comments 1. What assistance does the consumer need? 2. When is the assistance needed? 3. How often (Frequency) is assistance needed?

20 CAPS Comments 4. Factors contributing to the need for assistance. This is the Why? 5. If assistance is required; Who has been providing the assistance? 6. Do the consumer’s needs Fluctuate during a one month period?

21 CAPS Comments Example Ambulation: Assist Client had a dislocated R knee that needed surgery to fix. She uses a walker every time she ambulates and requires hands-on assistance at least once a week when her knee is weak and feels like it is going to give out. Daughter will hold on to her arm as she walks to provide extra support and balance. At this time she is unable to navigate stairs and avoids them. Grooming: Assist Client is unable to hold onto nail clippers due to her arthritis. Her daughter files her nails weekly unless client has extra money to have nails done at a salon. Toe nails are doen by a Podiatrist every 2 months by doctor’s orders. Client can manage her own hair care.

22 ACCESS Narration 1.Do not narrate protected information  HIV AIDS diagnosis or treatment.  Treatment in a Psychiatric Hospital or institution.  Genetic Testing or treatment.

23 ACCESS Narration 2.Do not narrate Adult Protective services investigation details.  You may narrate: “Today made APS report”  Never divulge the name of the APS reporter.  Look for the “Open Umbrella” icon for APS.

24 ACCESS Narration 3. Narrate all case actions and contacts with the client and people related to the case  Home visits and Assessments  CAPS completed and SPL level  Follow up information or planned activity  Phone calls, concerns, barriers, etc.

25 ACCESS Narration Examples HV today to meet/assess client for OPI services. Present for the interview were client (remained seated in recliner) and daughter, Ellen. Ellen comes over frequently and is a natural support. Client has limited mobility due to stroke and reports needing hands-on assist with some ADLs. Client was alert but voice was slurred. Gathered financial information and discussed pay-in. CAPS results pending. CAPS complete and client is SPL 7 and qualifies for OPI. Fee determination form complete and client will pay 10% of HCW costs. Called Dau Ellen and client is willing an able to pay her cost for the full 20 hours per month. Plan is for the paid HCW to do tasks that natural support cannot do. Mailed eligibility letter.

26 ACCESS Narration Examples Phone call from Dau Ellen today. Client has interviewed and hired HCW Sally Smith who will begin working in the home on the 11 th. Approved an OPI service Benefit, Hours, and Plan for 20 hours a month, with HCW getting 1 voucher per month. Mailed Task list to both parties. Mailed HCW forms to client for signature and return. Mailed HCW form 4105 authorization. CM phoned client and plan is working well. She is happy with her HCW and they get along well. HCW is coming 3X week for about 1 ½ hours. Client asked about HDM, I told her those were not available through OPI in our area and I will mail information for the Loaves & Fishes meals that can be purchased privately.

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