Oregon Administrative Code

411-068-0090 Civil Penalties (1) Civil penalties, not to exceed $200 per violation per day, may be assessed for a facility operating without a current registration. (2) Any civil penalty imposed under this section shall become due and payable when the person incurring the penalty…

411-069-0000 Definitions Unless the context indicates otherwise, the following definitions apply to the rules in OAR chapter 411, division 069: (1) "Assessment Rate" means the rate established by the Director of the Oregon Department of Human Services. (2) "Assessment Year" means…

411-069-0010 General Administration (1) The purpose of these rules is to implement the long term care facility assessment imposed on long term care facilities in Oregon. (2) The Department shall administer, enforce, and collect the long term care facility assessment. (3) The Depa…

411-069-0020 Disclosure of Information (1) Except as otherwise provided by law, the Department may not publicly divulge or disclose the amount of income, expense, or other particulars set forth or disclosed in any report or return required in the administration of the assessments…

411-069-0030 Entities Subject to the Long Term Care Facility Assessment Each long term care facility in Oregon is subject to the long term care facility assessment except for long term care facilities operated by the Oregon Department of Veterans' Affairs. Statutory/Other Authori…

411-069-0040 Long Term Care Facility Assessment: Calculation, Report, Due Date (1) The assessment is assessed upon each patient day, including Medicaid patient day, at a long term care facility. The amount of the assessment equals the assessment rate times the number of patient d…

411-069-0050 Filing an Amended Report (1) Claims for refunds or payments for additional assessment must be submitted by the facility on a form approved by the Department. The facility must provide all information required on the report. The Department may audit the facility, requ…

411-069-0060 Determining the Date Filed For the purpose of these rules, any reports, requests, appeals, payments, or other response by the facility must be either received by the Department before the close of business on the date due, or if mailed, postmarked before midnight of …

411-069-0070 Assessment on Failure to File In the case of a failure by the facility to file a report or to maintain necessary and adequate records, the Department shall determine the assessment liability of the facility according to the best of its information and belief. Best of…

411-069-0080 Consequence of Failure to File a Report or Failure to Pay Assessment When Due (1) A long term care facility that fails to file a quarterly report or pay a quarterly assessment when due under OAR 411-069-0040 is subject to a penalty of $500 per day of delinquency. The…

411-069-0090 Departmental Authority to Audit Records (1) The facility must maintain clinical and financial records sufficient to determine the actual number of patient days for any calendar period for which an assessment may be due. (2) The Department or its designee may audit th…

411-069-0100 Notice of Proposed Action (1) Prior to issuing a notice of proposed action, the Department shall notify the facility of a potential deficiency or failure to report that may give rise to the imposition of a penalty. The Department shall issue a 30 day notification let…

411-069-0110 Required Notice (1) Any notice required to be sent to the facility shall be sent to the current licensee and any former licensee who was occupying the property during the time period to which the notice relates. (2) Any notice required to be sent from the facility to…

411-069-0120 Hearing Process (1) Any facility that receives a notice of proposed action may request a contested case hearing as provided under ORS chapter 183. (2) The written request must be received by the Department within 20 days of the date of the notice. (3) Prior to the he…

411-069-0130 Final Order of Payment The Department shall issue a final order of payment for deficiencies and/or penalties when: (1) Any part of the deficiency or penalty is upheld after a hearing; (2) The facility did not make a timely request for a hearing; or (3) Upon the stipu…

411-069-0140 Remedies Available after Final Order of Payment (1) Any amounts due and owing under the final order of payment and any interest thereon may be recovered by Oregon as a debt to the state, using any available legal and equitable remedies. These remedies include, but ar…

411-069-0150 Calculation of Long Term Care Facility Assessment (1) The amount of the assessment is based on the assessment rate determined by the Director multiplied by the number of patient days at the long term care facility for a calendar quarter. (2) The Director shall establ…

411-069-0160 Limitations on the Imposition of the Long Term Care Facility Assessment The long term care facility assessment may be imposed only in a calendar quarter for which the long term care facility reimbursement rate that is part of the Oregon Medicaid reimbursement system …

411-069-0170 Sunset Provision The long term care assessment applies to long term care facility gross revenue received on or after June 2003 and before July 1, 2032. Statutory/Other Authority: ORS 409.050, 410.070 & 411.060 Statutes/Other Implemented: ORS 409.750, OL 2003, ch 736 …

411-070-0000 Purpose The purpose of these rules is to control payment for nursing facility services provided to Medicaid residents. Statutory/Other Authority: ORS 410.070 & 414.065 Statutes/Other Implemented: ORS 410.070 & 414.065 History: SPD 15-2009, f. 11-30-09, cert. ef. 12-1…

411-070-0005 Definitions Unless the context indicates otherwise, the following definitions and the definitions in OAR 411-085-0005 apply to the rules in OAR chapter 411, division 070: (1) "Accrual Method of Accounting" means a method of accounting where revenues are reported in t…

411-070-0010 Conditions for Payment Nursing facilities must meet the following conditions in order to receive payment under Title XIX (Medicaid): (1) CERTIFICATION. (a) The facility must be in compliance with Title XIX federal certification requirements. (b) Except as provided in…

411-070-0015 Denial, Termination or Non-Renewal of Provider Agreement (1) Failure to Comply. The Department reserves the right to deny, terminate or not renew contracts with providers who fail to comply with OAR 411-070-0000 through 411-070-0470 relating to nursing facility servi…

411-070-0020 On-Site Reviews The facility must allow periodic on-site reviews of Medicaid residents as required by federal regulations. Statutory/Other Authority: ORS 410.070 & 414.065 Statutes/Other Implemented: ORS 410.070 & 414.065 History: SPD 9-2006, f. 1-26-06, cert. ef. 2-…

411-070-0025 Basic Flat Rate Payment (Basic Rate) (1) PAYMENT. SPD may authorize payment at the basic rate if a Medicaid resident requires daily, intermittent licensed nurse observation and continuous nursing care and has a physician's order for nursing facility care. When determ…

411-070-0027 Complex Medical Add-On Payment (1) PAYMENT. APD may provide payment for a complex medical add-on (in addition to the basic rate) when the resident requires one or more of the treatments, procedures, and services listed in OAR 411-070-0091, for the additional licensed…

411-070-0028 Bariatric Authorization and Payment (1) PRIOR AUTHORIZATION. APD may authorize payment for the bariatric rate when a Medicaid individual’s needs meet the criteria listed in OAR 411-070-0087. A nursing facility must obtain prior authorization from the Department prior…

411-070-0029 Pediatric Rate (1) The pediatric rate shall be for those facilities meeting the criteria established in OAR 411-070-0452 as pediatric nursing facilities or as self-contained pediatric units. (2) The pediatric rate shall constitute the total rate payable by SPD on beh…

411-070-0033 Post Hospital Extended Care Benefit (1) The post hospital extended care benefit (OAR 410-120-1210(4)) is an Oregon Health Plan benefit that consists of a stay of up to one hundred (100) days in a nursing facility to allow discharge from hospitals. (2) The post hospit…

411-070-0035 Complex Medical Add-On Effective Start and End Dates and Administrative Review (1) Effective Complex Medical Add-On Start and End Dates (a) Complex Medical Add-On Start Date: (A) Admission of any Medicaid resident whose condition or service needs meet the criteria fo…

411-070-0040 Screening, Assessment, and Resident Review (1) INTRODUCTION. All individuals who are candidates for admission to a Medicaid-certified nursing facility must be assessed to evaluate their service needs and preferences and must receive information about community-based,…

411-070-0043 Pre-Admission Screening and Resident Review (PASRR) (1) INTRODUCTION. PASRR was mandated by Congress as part of the Omnibus Budget Reconciliation Act of 1987 and is codified in Section 1919(e)(7) of the Social Security Act. Final regulations are contained in 42 CFR, …

411-070-0045 Facility Payments (1) PRIOR AUTHORIZATION. The Department may reimburse a nursing facility for services provided to a Department resident only if prior authorized after the Department has participated in development of the placement plan and is satisfied that the pla…

411-070-0050 Days Chargeable The Department will pay for the day of admission but not for the day of discharge, transfer, or death except as provided for in OAR 411-070-0110. When the day of admission is the same as the day of discharge, the Department will only pay for one day. …

411-070-0075 Rates - Facilities in Oregon (1) The daily rate of payment for Oregon facilities will be the basic rate. (2) A nursing facility may receive payment for complex medical rate if all of the criteria in OAR 411-070-0091 is met. (3) A nursing facility may receive payment …

411-070-0080 Out-of-State Rates Out-of-state facilities in areas contiguous to Oregon shall be paid for eligible individuals who are receiving temporary care while alternative placement in Oregon is being located. Payment shall be made at the facility's Medicaid rate established …

411-070-0085 Bundled Rate (1) PURPOSE. The nursing facility rate established for a facility is a bundled rate and includes all services, supplies and facility equipment required for services. (2) SERVICES AND SUPPLIES. (a) The following services and supplies required to provide s…

411-070-0087 Bariatric Criteria and Services (1) A Medicaid eligible individual qualifies for the bariatric reimbursement rate if the individual has a physician diagnosis of obesity with a BMI>40 and the individual meets the following criteria as defined in OAR chapter 411, divis…

411-070-0091 Complex Medical Add-On Services (1) LICENSED NURSING SERVICES. If a Medicaid resident qualifies for payment at the basic rate and if the resident’s condition or service needs are determined to meet one or more of the procedures, routines, or services listed in this r…

411-070-0092 Ventilator Assisted Program - Medicaid Payment (1) PAYMENT- A Medicaid eligible individual qualifies for the Ventilator Assisted Program reimbursement rate if the: (a) Individual meets the criteria described in section (2) of this rule; and (b) The Nursing facility p…

411-070-0095 Resident Funds (1) Each Medicaid resident is allowed a monthly amount for personal incidental needs. For purposes of this rule, personal incidental funds (PIFs) include monthly payments as allowed and previously accumulated resident savings. (2) FACILITY RESPONSIBILI…

411-070-0100 Audit of Personal Incidental Funds (1) Records Available to Department. All account records and expenditure receipts for the resident's personal incidental funds must be available in the facility for audit and inspection by representatives of the Department of Human …

411-070-0105 Resident Property Records (1) Current Records. The facility must maintain a current, written record for each resident that includes written receipts for all personal possessions deposited with the facility. (2) Availability. The property record must be available to t…

411-070-0110 Temporary Absence from Facility (Bedhold) (1) SPD does not pay for holding a resident's bed when the individual is absent from the facility. (2) Personal incidental funds or payment from an individual's family may be used to hold a facility bed if there are no vacanc…

411-070-0115 Transfer of Residents (1) Prior Approval Required. A resident must not be transferred to another facility without prior approval by the resident, the attending physician, branch worker, and the facility's director of nursing services. Reassignment of rooms within the…

411-070-0120 Discharge of Residents When the attending physician indicates that the resident does not, or in the future will not, require long-term care, facility authorities must report this fact to the branch office no later than the first branch office working day following th…

411-070-0125 Medicare, (Title XVIII) SPD shall pay on behalf of eligible individuals the coinsurance rate established under Medicare, Part A, Hospital Care, for care rendered from the 21st day through the 100th day of care in a Medicare certified nursing facility. SPD shall pay t…

411-070-0130 Medicaid Payment in Hospitals (1) SWING BED ELIGIBILITY. To be eligible to receive a Medicaid payment under this rule, a hospital must: (a) Have approval from the Centers for Medicare and Medicaid Services (CMS) to furnish skilled nursing facility services as a Medic…

411-070-0140 Hospice Services (1) CONTRACT. (a) The Department enters into a contract (provider agreement) to reimburse Medicare certified hospice providers in Oregon for services provided in Medicaid certified nursing facilities under the following conditions: (A) The Medicare-c…

411-070-0300 Filing of Financial Statement (1) The provider must file annually with the Department, Financial Audit Unit, the Nursing Facility Financial Statement (NFFS) covering actual costs based on the facility's fiscal reporting period for the period ending June 30. A NFFS mu…