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APD Worker Guide

D.8 Services for Adults with Intellectual/Developmental Disabilities

Updated 9/4/19

1. Intellectual/Developmental Disabilities Terminology
2. Eligibility Overview
3. DD Services for OSIPM Eligible Adults
4. Post Eligibility and Service Contribution
5. Coordination
6. Contacts

1. Intellectual/Developmental Disabilities (I/DD) Terminology

Developmental Disability (DD): Certain disabilities that originate in childhood, significantly impact adaptive behavior, and both the condition and impairment are expected to last indefinitely. Developmental disabilities may include autism, cerebral palsy, epilepsy, or other neurological disabling conditions that require training or support similar to that required by individuals with an intellectual disability (ID). To be considered a developmental disability, the disability must:

Intellectual Disability (ID): History of intellectual disability and significant impairment in adaptive behavior directly related to the intellectual disability must be evident prior to the 18th birthday. Intellectual disability means significantly sub average general intellectual functioning defined as full scale intelligence quotients (FSIQs) 70 and under, as measured by a qualified professional, and existing concurrently with significant impairment in adaptive behavior directly related to an intellectual disability that manifested prior to an individual’s 18th birthday.  Individuals with a valid FSIQ score of 66 – 70 require verification of intellectual disability with an assessment of adaptive behavior evidencing significant impairment directly related to the intellectual disability. Individuals with valid FSIQ scores of 71 – 75 require an adaptive behavior assessment evidencing significant impairment and a diagnosis of intellectual disability by a licensed clinical psychologist.

Community Developmental Disabilities Program (CDDP): Case Management Entity (CME) that is responsible for I/DD disability determination for eligibility, plan authorization, delivery, and monitoring of services for individuals with I/DD. A CDDP operates in a specific geographic service area of the state under a contract with the ODDS, local mental health authority, or other entity as contracted by ODDS.

Brokerage: A CME that is responsible for plan authorization, delivery, and monitoring of services for individuals with I/DD. A brokerage operates in a specific geographic service area of the state under a contract with the ODDS.

In-Home Supports: Like APD, individuals with I/DD may choose to have services provided in their own home. Individuals may choose to hire a Personal Support Worker (PSW), use an agency with Direct Service Providers (DSP), or a combination of both to provide care.

Supported Living: A comprehensive service available only to DD adults who are case managed by a CDDP, not a Brokerage. Individuals may live in-home or in a provider-controlled site. There is a variety of allowable models in Supported Living.

Provider controlled:

Note: The Supported Living service cannot be tied to the individual’s housing. If the individual chooses to use a different provider, it cannot result in an eviction for exercising the choice of provider.

Not provider controlled:

Note: In this guide, the term “individual with I/DD” is used to refer to someone with an intellectual or developmental disability who has been determined eligible for programs through the Office of Developmental Disabilities Services.

2. Eligibility Overview

Medicaid Eligibility

Like many others, individuals with I/DD can be eligible for MAGI, Child Welfare (CW) medical, or for OSIPM. Individuals with I/DD who are eligible for MAGI, CW, or OSIPM medical may receive K Plan (DDK) or DD Comprehensive (DDC) waivered services if they choose and if they meet the Level of Care requirements.
Individuals with I/DD can be eligible for OSIPM in a variety of ways:

Individuals with I/DD may have special considerations related to Medicaid eligibility.  Although the Medicaid eligibility rules are the same, the types of Home and Community Based Services (HCBS) waivers are different for those with intellectual and developmental disabilities than they are for those with physical disabilities.  The main differences are:

The process for determining Medicaid eligibility is essentially the same for all individuals. To provide medical benefits to an individual, staff must:

Medicaid eligibility is established by APD/AAA, CW, or OHA staff.
The primary difference is in who determines service eligibility and provides the case management for services. This may be done by many different entities. The primary use of the service category code is to identify the basis of the individual’s service eligibility and the range of services (waivered services, personal care, etc.). The service category codes also help identify the group that makes the service eligibility decision. The following are the staff that perform case management:

See ODDS Cases…Who Does What?

Note: All cases will be held in the local APD/AAA office. Please see the Worker Guide on children's service eligibility for more information.

Service Eligibility

Individuals who have been determined eligible for I/DD services and have open Medicaid may receive long-term care services. Like APD, those may include employment, transportation, ADL/IADL services among others. Those who do not have Medicaid are eligible for case management only, or for children, the general fund Family Support program provides a limited annual support allotment.

The CDDP Eligibility Specialist completes an I/DD disability determination within 90 days and will approve eligibility through their own system called Express Payment & Reporting System (eXPRS). After eligibility is approved a case manager is assigned, Choice Advising occurs where the individual decides which K plan and/or waiver services they are interested in, and a case plan is created with the individual within 90 days from the date of the completed application for DD services or start of Medicaid eligibility. If the individual chooses a Waiver service, then the Oregon Needs Assessment (ONA) will be completed by a qualified assessor and establish Level of Care (LOC); institutional level of care for an ICF/IID). Once the DD service eligibility information is submitted by the case manager through eXPRS, the TAU will add the appropriate codes to the non-CAPS service eligibility table (SELG).  The FSG and FSL codes may also be used in SELG and indicate the individual (a child) is receiving DD Case Management and Family Support services. If the FSG or FSL codes appear on SELG, the NSS code will have to be replaced on PCMS or CMUP with the corresponding code, even though the individual is not on a waiver.

Staff may view the Non-CA/PS Service Eligibility Table by typing “SELG, {prime number}” on a blank screen. If the SELG screen does not display the information needed, staff can access SL01 by selecting F3 from the SELG record. If a record exists, it will show up with the beginning and ending dates of eligibility as well as the service or waiver eligibility category (Cat Cd). If a record exists for the service period, the CMS record can be updated.

3. DD Services for OSIPM Eligible Adults

There are several types of DD service options available for adults who meet the I/DD eligibility criteria. Each requires Medicaid eligibility through OSIPM, Child Welfare medical, or MAGI and have different codes in the SELG system.

Note: For the remainder of this Worker Guide, we will refer only to OSIPM medical where eligibility is determined by APD/AAA staff. However, this information could apply to individuals receiving MAGI or CW medical programs.

To be eligible for one of the above, an individual must meet all three qualifications:

DD Adult Residential or In-Home Care

Establish Service Eligibility/Waiver Eligibility:

Establish Medical Eligibility:

Case Coding:

DD Non-Relative Foster Care:

Program Code: _1, A1, _3, B3, _4, D4, or _5
Case Descriptors: DDC/DDK/ DDG, CBF, DAN
Needs/Resource Codes: MVC (Continuous 0.00), Code Income and Deductions as Appropriate

DD 24-Hour Residential/Supported Living:

Program Code: _1, A1, _3, B3, _4, D4, or _5
Case Descriptors: DDC/DDK/DDG, CBF, GCH
Needs/Resource Codes: MRF (Continuous 0.00), Code Income and Deductions as Appropriate

DD In-Home:

Program Code:

_1, A1, _3, B3, _4, D4, or _5

Case Descriptors:

DDC/DDK/DDG

Needs/Resource Codes:

Code Income and Deductions as Appropriate

 

DD State Plan Personal Care

Establish DD Disability Eligibility (State Plan; Non-waiver):

Establish Medical Eligibility:

Case Coding:

Program Code:

_1, A1, _3, B3, _4, D4, or _5

Case Descriptors:

BPD

Needs/Resource Codes:

Code Income and Deductions as Appropriate

DD Nursing Facility Stay

Individuals whose primary diagnosis is I/DD or a serious mental illness are not eligible for NF services if their needs can be met in the community, regardless of age. See OAR 411-070-0043 for more information. APD/AAA offices must contact the PASRR II coordinator via email, at OR.PASRR@state.or.us, to request and receive approval BEFORE opening a nursing facility plan of care on MMIS.  The local APD/AAA office sets up the nursing facility service plan and plan of care if approved in the PASRR-II process.


Local APD/AAA Action:

To open the nursing facility services:

To close the nursing facility services:

More Coding Help:

DD Medical Program Coding chart
eXPRS Client Profile Information Codes

4. Post Eligibility and Service Contribution:

All post eligibility rules apply, and excess income used to reduce the cost of care will be contributed through the appropriate payments system based on the financial information in CMS. The significant difference is the system used for collection of the individual contribution:

If individuals change service settings or programs, liabilities may also change. In those instances, APD/AAA staff must send a continuing benefit notice informing the individual of the new payment responsibility (use the 540P).

5. Coordination:

This section clarifies how the DD offices and the APD/AAA offices should coordinate services for individuals with I/DD.

Determining DD service eligibility for Adults under 65: Individuals must have their I/DD determination establishing eligibility as a first step prior to any service authorization. If found to meet eligibility requirements, all services are then coordinated via the chosen CME (except for nursing facility stays).

The local CDDP office will complete a disability determination through a review of the individual’s existing records and test scores and comparing that information to the applicable Oregon Administrative Rules for DD service eligibility. If the individual is determined eligible for DD services, they may choose to receive service coordination through the CDDP or a brokerage service provider.

Individuals under 65 may receive APD services while they are waiting to be evaluated or approved for DD services if they meet State Plan Personal Care or SPL and all other eligibility requirements. Once they are approved for DD services, however, APD services should close following a timely continuing benefit notice, and coordinate with opening services at the CDDP or brokerage.

Determining DD service eligibility for Adults over 65: Individuals with I/DD who are 65 and over may choose to be served within the APD or DD system, if they meet service eligibility for both. This assessment is most often facilitated via the DD service planning team process.  Services cannot be provided to these individuals under both waivers at the same time. If a person is transitioning from one service system to another, the sending agency will send a timely continuing benefit notice and stop services concurrently with services opening with the receiving agency.

Communication: Communication between APD/AAA offices and ODDS CME’s is essential to DD service coordination. When an individual meets eligibility criterion, changes addresses and/or care plans (i.e. goes from Supported Living to in-home services so no longer has a collected liability) or reports any other change that may affect the OSIPM case, the CME should notify the APD/AAA office.

When an individual is eligible for retroactive medical, becomes eligible for EPD, or requires an immediate/retro adjustment in liability, the APD/AAA office should notify the TAU as these changes require manual updates in eXPRS. Any other change that may affect services should be sent to the CME.

Annual redeterminations by APD/AAA and DD for financial and service eligibility may be coordinated for efficiency.

6. Contacts

DD Business Analyst: Kolette Ropp 503-945-5984

OSIPM and QMB Eligibility:

Janell White 541-507-7423
CBC Payment Processing Kristen Hutton 503-945-6741
TAU DD Central Support 503-945-5984
ODDS Eligibility Policy Rebecca Smallwood 503-957-9016

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Oregon Department of Human Services
500 Summer St. NE E02, Salem, OR 97301-1073
Phone: (503) 945-5811
Toll-free: (800) 282-8096 (V/TTY)