Situation

540 reason should include:

1. Whereabouts unknown (SDS 540)

Note:  For SNAP, no notice is required when you receive returned mail.  Code FCAS with RM for “returned mail” and close SNAP for the end of the month.

We have received returned mail for this address stating you have moved & left no forwarding address.  Since we cannot locate you, we are closing your medical benefits. OAR 410-120-1210, 461-175-0210, 461-105-0020, 461-120-0010

2. Move out of state (Residency) (SDS 540)

 Note: For SNAP, no notice is required when the filing group moves out of state. See 461-175-0200 and 461-175-0210

The Department will end your medical benefits on mm/dd/yy. You are no longer an Oregon resident. You must be a resident to receive benefits from Oregon programs. OAR 410-120-1210, 461-120-0010, 461-120-0030, 461-165-0030, 461-120-0010, 461-120-0030, 461-120-0050

3. Client is no longer eligible for SERVICES & does not qualify for any medical benefits (SDS 540 & DHS 462A)

Send a separate 540 for services. Additionally, for in-home services, send a DHS 4105 to the HCW prior to ending services.

Because you are no longer eligible for waivered service, you are no longer eligible for Oregon Supplemental Income Program - Medical (OSIPM). To be eligible for OSIPM without waivered services, you must have income below the program income standard. Your income of $_____ exceeds the OSIPM standard. Your income is also over the income standards for the Qualified Medicare Beneficiary (QMB) programs that pay Medicare premiums. Effective mm/dd/yy you will be responsible for your Medicare premiums, some co-pays and deductibles. You are not eligible for the Oregon Health Plan because you have Medicare. 410-120-1210; 411-015-0005 through 411-015-0015; 461-135-0750; 461-135-1100; 461-155-0250, 0290, & 0295

5. Failure to return review packet for medical. (SDS 540) 

We must periodically review your case to determine whether you meet the requirements for Medicaid. This review is required to be done at least once every 12 months.  Your review was due on mm/yy. We mailed you an application to renew your benefits. We have not received the application back from you. OAR 410-120-1210, 461-105-0020, 461-115-0430.

6. Failure to provide requested verification (SDS 540)

We requested verification from you regarding [insert verification type].  To date, we have not received this requested verification. Because we have not received this information, your benefits will close on mm/dd/yy. OAR 410-120-1210, 461-105-0020, 461-115-0010, 461-115-0020, 461-115-0190, 461-115-0705, 461-115-0700, 461-115-0610, 461-115-0430 (EPD add: 461-115-0540)

7. Closure of EPD for failure to make monthly participant fee (SDS 540 & DHS 462A)

As an eligibility requirement of the Employed Person with Disabilities (EPD) program, you are required to pay a participant fee each month. Based on your income of $____, you must pay $____ each month to have EPD eligibility.  This payment is due by the 10th of each month.  You have not made your monthly payment for the month(s) of mm/yy.  The Department has considered other medical programs and it was determined that you do not qualify for any Medicaid program at this time. OAR 410-120-1210, 461-001-0035, 461-160-0800

8. Loss of SSI & the client is not entitled to any other medical benefits.  (SDS 540 & DHS 462A)

Note: Make sure the client didn’t lose SSI based on their earned income. If so, they may be considered 1619B eligible & continue with OSIPM.  Also consider OHP – average 3 months income.

You are no longer eligible for Oregon Supplemental Income Program-Medical (OSIPM) because you no longer receive SSI benefits and your income from _____ of $______ puts you over the income standard for OSIPM. The Department has considered other medical programs and it was determined that you do not qualify for any Medicaid program at this time. OAR 461-001-0000, 461-155-0250, 461-155-0290, 461-155-0291, 461-155-0225, 461-155-0295, 461-135-1100, 461-160-0540, 461-160-0550, 461-160-0551, 461-160-0552, 410-120-1210

You are no longer eligible for Oregon Supplemental Income Program-Medical (OSIPM) because your new income from _____ of $______ puts you over the income standard for OSIPM. The Department has considered other medical programs and it was determined that you do not qualify for any Medicaid program at this time. OAR 461-001-0000, 461-155-0250, 461-155-0290, 461-155-0291, 461-155-0225, 461-155-0295, 461-135-1100, 461-160-0540, 461-160-0550, 461-160-0551, 461-160-0552, 410-120-1210

10. Client does not meet DAC eligibility criteria.  (SDS 540 & DHS 462A)

To be eligible under the disabled adult child criteria for Oregon Supplemental Income Program - Medical (OSIPM): You must  be at least 18 years of age; You must have been determined by SSA to be blind or disabled prior to age 22; You must have lost your SSI because you started receiving disabled adult child benefits or received an increase in these benefits that caused you to lose your SSI; and you must have lost your SSI due to receipt of disabled adult child benefits after 7/1/1987. The circumstances in your case do not meet the criteria described above. The Department has considered other medical programs and it was determined that you do not qualify for any Medicaid program at this time. OAR 410-120-1210, 461-001-0000, 461-135-0830; 461-155-0250; 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552

11. Closure of OSIPM & QMB programs for over resources (SDS 540 & DHS 462A)

Note: If SBI client, remove Medicare Savings Program language.

You have resources that exceed the $2000 limit for the Oregon Supplemental Income Program-Medical (OSIPM). Your resources also exceed the $6,940 limit for the Medicare Savings Program [QMB/SMB/SMF]. Effective mm/dd/yy your OSIPM Plus medical benefits and Medicare Savings Program will end. Effective mm/dd/yy you will be responsible for your Medicare premiums, some copays and deductibles. You are not eligible for the Oregon Health Plan because you have Medicare. OAR 410-120-1210; 461-160-0010; 461-160-0015

12. Binding SSA decision (SDS 540 & DHS 462A)

Note: Consider OHP – average 3 months income.

You must be determined disabled to qualify for the Oregon Supplemental Income Program-Medical (OSIPM) through which you have been receiving Plus benefits. Social Security Administration disability decisions are binding on the state Medicaid agency, even if you are appealing them. SSA decided you are not disabled. To our knowledge you have no new disabling condition that SSA is not considering. The Department has considered other medical programs and it was determined that you do not qualify for any Medicaid program at this time. OAR 410-120-1210, 461‑125‑0310, 461-125‑0370

13. Binding SSA Appeals Council decision (SDS 540 & DHS 462A)

Note: Consider OHP – average 3 months income.

You must be determined disabled to qualify for the Oregon Supplemental Income Program-Medical (OSIPM) through which you have been receiving Plus benefits. Disability decisions by the Social Security Administration Appeals Council are binding on the state Medicaid agency, even if you are appealing them. On mm/yy the Appeals Council decided you are not disabled. To our knowledge you have no new disabling condition that SSA is not considering. The Department has considered other medical programs and it was determined that you do not qualify for any Medicaid program at this time. OAR 410-120-1210, 461‑125‑0310, 461-125‑0370

14. No longer an Oregon resident

In order to receive services in Oregon you must be living in Oregon. According to our information you no longer reside in Oregon. OAR 461-120-0010

15. Inmate of an institution

1. OSIPM to QMB benefits (SDS 540)

Your current adjusted income places you over income for Oregon Supplemental Income Program-Medical (OSIPM).  The Oregon Health Plan is not available to you because you have Medicare.  The only program you qualify for is the program that pays your Medicare premiums, some co-pays & deductibles. OAR 461-001-0000, 461-155-0250; 461-155-0290; 461-135-1100; 461-160-0540; 461-110-0210, 0310, 0410, 0530 & 0750; 461-160-0550; 461-160-0551; 461-160-0552; 410-120-1210

2. OSIPM to SMB or SMF due to increased income or change in income (SDS 540)

Your current monthly income places you over the income limit for the Oregon Supplemental Income Program-Medical (OSIPM). The only program you qualify for is the program that pays your Medicare Part B premium. You are not eligible for the Oregon Health Plan because you have Medicare. OAR 461-001-0000, 461-155-0250; 461-155-0290; 461-155-0295; 461-135-1100, 461-160-0540; 461-110-0210, 0310, 0410, 0530 & 0750; 461-160-0550; 461-160-0551; 461-160-0552; 410-120-1210

3. QMB to SMB or SMF due to a change in income or annual income standard change. No OSIPM eligibility. (SDS 540)

Your current adjusted income places you over income for the Qualified Medicare Beneficiary (QMB) program which pays your Medicare premiums, deductibles, and some co-payments. The only program you qualify for is the [SMB/SMF] program that pays your Medicare Part B premium. ([SMB/SMF] does not pay co-pays or deductibles). You are not eligible for the Oregon Health Plan because you have Medicare. OAR 461-001-0000, 461-155-0250, 461-155-0290, 461-155-0295, 461-135-1100, 461-160-0540, 461-160-0550, 461-160-0551, 461-160-0552, 410-120-1210

4. Reduction from OHP Plus to OHP Standard (PMDDT client gets approved for SSD; SSD is under the OHP income limit and the client does not yet have Medicare & is under the $2000 resource limit)  (SDS 540)

You have new income that must be considered in determining your eligibility for the Oregon Supplemental Income Program-Medical (OSIPM) that offers you Plus benefits. Your income puts you over the income limit for OSIPM. The only program you qualify for is Oregon Health Plan (OHP) Standard benefits. The benefit package under OHP Standard is more limited than the Plus benefits. OAR 461-001-0000, 461-155-0250, 461-155-0225, 461-135-1100, 461-160-0540, 461-160-0550, 461-160-0551, 410-120-1210

5. Reduction from OSIPM to QMB/SMB/SMF due to no longer considered DAC eligible.  (SDS 540)

Note: When removing the DAC C/D, make sure incoming code is SUPL or COMP so the case will recalculate.

To be eligible under the disabled adult child criteria for Oregon Supplemental Income Program-Medical (OSIPM), you must be at least 18 years of age; You must have been determined by SSA to be blind or disabled prior to age 22; you must have lost your SSI because you started receiving disabled adult child benefits or received an increase in these benefits that caused you to lose your SSI; and you must have lost your SSI due to receipt of disabled adult child benefits after 7/1/1987. The circumstances in your case do not meet the criteria described above. The only program you qualify for is the [QMB/SMB/SMF] program which pays your monthly Medicare premium [, some co-payments and deductibles]. OAR 410-120-1210; 461-001-0000, 461-135-0830; 461-155-0250; 461-155-0295; 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-155-0290; 461-135-1100; 461-110-0210, 0310, 0410,0530 & 0750

1. Failure to provide requested verification (SDS 540)

We requested verification from you regarding [insert verification type].  To date, we have not received this requested verification. Because we have not received this information, you are not eligible for benefits. OAR 410-120-1210, 461-105-0020, 461-115-0010, 461-115-0020, 461-115-0190, 461-115-0705, 461-115-0700, 461-115-0610, 461-115-0430 (Add for EPD: 461-115-0540)

2. Denial - OHP. Not eligible. (540 & 462A)

The Oregon Health Plan (OHP) program is closed to new applicants unless selected from the reservation list. Your date of request for OHP is mm/dd/yy. You are considered a new applicant for OHP because your date of request is after July 1, 2004 and you were not selected from the reservation list. The Department has considered other medical programs and there are no medical programs for which you are eligible. OAR 410-120-1210, 461-135-1102

You are not eligible for OHP because you have Medicare. There will be no change to your current benefits. The Department has considered all programs and you are receiving the correct benefits. OAR 410-120-1210, 461-135-1102, 461-155-0250, 461-160-0540, 461-160-0550 

5. Denial of Medical benefits for not meeting citizenship/alien status requirements.  (540 & 462A)

Note: Consider CAWEM for this client under 461-135-1070. See CAWEM manual for more info.

To receive Medicaid benefits, you must be a U.S. citizen or meet the requirements of a qualified non-citizen. You entered the United States on mm/yy.  You are not considered a refugee or here under asylum.  You do not meet any of the other special criteria for U.S. residency.  You are not on active duty or a veteran of the U.S. armed forces. You have not lawfully resided in the U.S. for 5 years.  You do not qualify for Medicaid benefits. OAR 410-120-1210, 461-120-0110, 461-120-0125

6. Denial of OSIPM for being over income  (540 & 462A)

You are not eligible for Oregon Supplemental Income Program-Medical (OSIPM) because you are over the income standard. You are not eligible for any other Medicaid program. OAR 461-155-0250, 461-160-0550, 461-160-0551, 461-160-0552, 410-120-1210

9. Denial of presumptive disability based on SSA decision (540 & 462A)

You must be determined disabled to qualify for the Oregon Supplemental Income Program-Medical (OSIPM) that provides the Plus benefit package. Social Security Administration disability decisions are binding on the state Medicaid agency, even if you are appealing them. SSA decided you are not disabled. To our knowledge, you have no new disabling condition that SSA failed to consider. The Department has considered other medical programs and it was determined that you do not qualify for any medical program at this time. OAR 410-120-1210; 461-125-0310, 461-125-0370.

10. Denial of OSIPM based on PMDDT decision that client isn’t disabled - client is not eligible for any programs (540 & 462A)

You must be determined disabled to qualify for the Oregon Supplemental Income Program-Medical (OSIPM). This program provides the Plus benefit package. After reviewing the medical and other evidence in your case, the Department has determined that you do not meet SSA disability criteria. The Department has considered other medical programs and it was determined that you do not qualify for any medical program at this time. OAR 410-120-1210; 461-125-0310; 461-125-0370;20 CFR Part 404, Subpart P, Appendix 1 & 2; 20 CFR 416.905

12. Denial of Presumptive Medicaid due to failure to comply with PMDDT.
(540 and 462A).

Your application for medical benefits under Oregon Supplemental Income Program Medical (OSIPM) is denied because you failed to comply with the eligibility requirements. In order to be eligible for OSIPM, clients must cooperate in obtaining sufficient medical documentation for the Department to determine eligibility. You failed to cooperate in obtaining sufficient medical documentation by failing to attend a medical examination that was scheduled for mm/dd/yy at hh:mm with Dr. _________ and rescheduled for mm/dd/yy at hh:mm. OAR 410-120-1210, 461-105-0020, 461-125-0830.

14. Denial of CAWEM under PMDDT because the client is not disabled (540 & 462A)

You must be determined disabled to qualify for the Medicaid program that provides the CAWEM Emergency Medical Services benefit package. After reviewing the medical and other evidence in your case, the Department has determined that you do not meet SSA disability criteria. The Department has considered other medical programs and it was determined that you do not qualify for any medical program at this time. OAR 461-135-1070; 410-120-1210; 461-125-0310; 461-125-0370; 20 CFR Part 404; Subpart P, Appendix 1 & 2; 20 CRF 416.905

15. Inmate of an institution

1. Denial of request for reimbursement for Medical Transportation
(Send a 540 or denial on Department letterhead as long as you attach the hearing rights and include the client’s name; case number; effective date; rules; explanation of action; and action you intend to take (deny, reduce or close). The hearing rights form is on the forms server DHS 447.)

You requested reimbursement for the following trips for medical appointments: 1) ___ 2)___ 3)___ etc.  Your request for reimbursement is denied. The client’s local branch office must authorize all reimbursement for client’s mileage in advance of the clients travel in order to qualify for reimbursement.  Our records do not show that you contacted our office to request prior authorization for transportation reimbursement for these appointments. Also, we will not authorize transportation from _____ to ____ for these appointments because all of these medical services are available in a city closer to _______. You state that it is your preference to not change your doctors and that you continue to receive medical treatment in the _____ area even though you live in ____. The Department will not make payment for transportation to a specific provider based solely on client preference or convenience.  For purposes of authorizing non-emergency medical transportation, the medical service or practitioner must be within the local area.  Local area is defined as “in or nearest” the clients city or town of residence.  OAR 410-136-0160, 410-136-0800

1. Client is over income due to receipt of new income

You have [new/a change in ] income that must be considered in calculating your food benefits. Adding this income to your food benefit case caused your benefits to be closed. You are over the income limit for the food benefit program. OAR 461-155-0190, 461-160-0400, 461-150-0070, 461-160-0430, 461-160-0420, 461-160-0060, 461-180-0050

2. Client is a resident of an institution

You were admitted to an institution on mm/dd/yy. Residents of institutions are not eligible for food benefits. OAR 461-135-0510

Your food benefits are ending because [you did not return your application, complete the intake, over income, etc]. Rules will vary based on reason. OAR 461-115-0450

1. Receipt of new income CASE NOT IN SRS

You have [new/a change in] income that must be used when calculating your food benefits. Adding this income to your case caused your food benefits to be reduced. OAR 461-155-0190, 461-160-0400, 461-150-0070, 461-160-0430, 461-160-0420, 461-160-0060, 461-180-0030

2. Change in shelter  expense CASE NOT IN SRS

You have had a change in your shelter amount. This change resulted in a decrease in your food benefits. Since your shelter cost went down, your food benefits went down. OAR 461-160-0420, 461-160-0060, 461-155-0190, 461-160-0400, 461-160-0430, 461-180-0030

4. Change in income CASE is in SRS

You have [new/a change in] income that must be considered in calculating your food benefits. Adding this income to your case caused your food benefits to go down. OAR 461-180-0006, 461-155-0190, 461-160-0400, 461-150-0070, 461-160-0430, 461-160-0420, 461-160-0060, 461-180-0030

5. Change in shelter expense CASE is in SRS

You have had a change in your shelter amount. This change resulted in a decrease in your food benefits.  When your shelter costs change, it changes your food benefits. Since your shelter costs went down, your food benefits went down. OAR 461-160-0420, 461-160-0060, 461-155-0190, 461-160-0400, 461-160-0430, 461-180-0030, 461-170-0020, 461-180-0006

6.Change in household composition

You have had a change in your household composition. The number of people in your household effects the amount of benefits you receive. Due to this change, your food benefits went down. OAR 461-110-0210, 461-110-0310, 461-110-0530, 461-110-0750

1. Receipt of Foods from California

Your application for food benefits for mm/yy is denied because you are receiving the California State Supplement with your Supplemental Security Income (SSI) benefits.  The SSI benefits issued from California include money for you to use to purchase food.  Because you are receiving the California State Supplement in mm/yy as verified with Social Security, we cannot approve your food benefits in Oregon for this same period of time.  You cannot get the same benefits from two different states for the same time period. OAR 461-165-0030, 461-110-0370

2. Client does not meet citizenship/alien status requirements

To receive food benefits, you must be a U.S. Citizen or meet the requirements of a qualified non-citizen. You entered the United States on mm/yy. You are not considered a refugee or here under asylum. You do not meet any of the other special INS criteria for U.S. residency. You have not worked 40 qualifying quarters while residing in the U.S.. You are not on active duty or a veteran of the US armed forces. You have not lawfully resided in the US for 5 years.  You do not qualify for food benefits. OAR 461-120-0110, 461-120-0125

6. Medical deduction denial
(choose one)

• Your request for a medical deduction for food benefits is being denied as you do not meet the food benefit definition of elderly or disabled. OAR 461-001-0015
  
  
• Your request for a medical deduction for food benefits is being denied as the reported expense is in the last month of your certification period.  Since the bill is already paid there is no adjustment to your food benefits. OAR 461-001-0000, 461-115-0450, 461-160-0415, 461-180-0020
  
  
• Your request for a medical deduction for food benefits is being denied as the reported medical expense was paid in full in a prior certification period and you can not claim the same bill twice. OAR 461-001-0000, 461-160-0030, 461-160-0415
  
  
• Your request for a medical deduction for food benefits is being denied as the reported medical expense is past due and you do not have an installment plan or the installment plan was defaulted on.  OAR 461-160-0415
  
  
• Your request for a medical deduction for food benefits is being denied as the reported medical expense is being paid by someone outside the food benefits filing group and cannot be claimed as an expense by you. OAR 461-160-0030
  
  
• Your request for a medical deduction for food benefits is being denied as the reported medical expense is not prescribed or provided by a medical practitioner.  OAR 461-160-0055
  
  
• Your request for a medical deduction for food benefits is being denied as the reported medical expense is for a person who is no longer in your household group. OAR 461-110-0210
  
  
• Your request for a medical deduction for food benefits is being denied. You are required to provide information when requested by the Department. We requested information from you about [specific medical verification/info requested on 539H]. You have not provided that verification. 461-105-0020, 461-115-0610, 461-115-0651, 461-001-0015, 461-160-0055 ,

Situation

540 reason should include:

1. Not OSIPM eligible (540)

Note: If the OSIPM eligibility is based on receipt of services, send a separate 540 to close/reduce medical.

2. Failure to employ an enrolled  HCW – Client has 14 business days within to employ a HCW

Note: If the OSIPM eligibility is based on receipt of services, send a separate 540 to close/reduce Medicaid.

You must employ an enrolled Homecare Worker or Contracted In-Home Care Agency in order for you to be eligible for community based care waivered services. You have gone more than 14 days without employing a homecare worker or contracted agency to provide in-home services authorized and paid for by DHS. Failure to comply with this requirement has resulted in closure of your community based care waivered services. OAR 411-030-0020, 411-030-0040

3. Client does not make a pay-in for services. 

Note: If the OSIPM eligibility is based on receipt of services, send a separate 540 to close/reduce medical.

The auto-generated "Services Termination Notice" serves as a timely continuing benefit notice. No 540 for services needed.

4. Client no longer meets the SPL.

Note: If the OSIPM eligibility is based on receipt of services, send a separate 540 to close/reduce medical.

Your ability to meet your personal care needs in activities of daily living has improved. This decision is based on the information obtained from you at an interview and assessment performed on mm/dd/yy. Your current service priority level is [SPL].  The Department serves service priority level 1 through 13. Since your current service priority level is not within this range, your long-term care services will end mm/dd/yy.  The Department has reviewed your eligibility for all service programs. OAR 411-015-0005 through 411-015-0100; 411-030-0020; 411-030-0050; 411-034-0000 through 411-034-0030

5. Not eligible as service needs related to mental or emotional disorder (MH)

Note: If the OSIPM eligibility is based on receipt of services, send a separate 540 to close/reduce medical.

You are not eligible for long-term care services because your need is based on a mental or emotional disorder. Home and Community Based Services may only be authorized for individuals under age 65 if the individual has a medical, non-psychiatric diagnosis or physical disability and the individual’s need for services is based on the medical, non-psychiatric condition. Medical documentation of the medical, non-psychiatric diagnosis or disability is required and must demonstrate the connection between service needs and the diagnosis or disability. OAR 411-015-0005 through OAR 411-015-0008; 411-015-0015

6. Not eligible for waivered services due to natural supports

Note: If the OSIPM eligibility is based on receipt of services, send a separate 540 to close/reduce medical.

You are not eligible for long-term care services because your natural support system is meeting all of your assessed service needs. This decision is based on the information gathered during your assessment and interview on mm/dd/yy. The Department can only authorize payment when natural support is unavailable, insufficient or inadequate to meet your service needs. Your natural support system is adequately meeting your service needs. The Department has reviewed your eligibility for all service programs. OAR 411-015-0000 through 411-015-0015; 411-027-0000; 411-030-0002 through 411-030-0070, 411-034-0000 through 411-034-0030

7. Not eligible for SPPC due to not needing assistance in Personal Care Services

You are not eligible for State Plan Personal Care Services because you do not require assistance from another person with one or more personal care services:  basic personal hygiene, toileting, bowel and bladder care, nutrition, mobility, transfers and comfort, medication and oxygen, delegated nursing tasks as described in OAR 411-034-0020. The Department has reviewed your eligibility for all long-term care service programs. OAR 411-034-0000 through 411-034-0070

8. Not eligible for SPPC due to Natural Supports

You are not eligible for State Plan Personal Care Services because your natural support system (family, friends, neighbors or community resources) is meeting all of your assessed service needs. The Department can only authorize payment when natural support is unavailable, insufficient or inadequate to meet your service needs. This decision is based on the information gathered during your assessment and interview with you on mm/dd/yy. The Department has reviewed your eligibility for all long-term care service programs. OAR 411-034-0000 through 411-034-0070

9. Determined eligible by Developmental Disability Program

Persons under age 65 who are determined eligible for developmental disability services are not eligible for services under the Title XIX 1915c Home and Community Based Services waiver. You were determined eligible by Developmental Disabilities Services on mm/dd/yy.  Therefore, you are not eligible for Title XIX Home and Community Based Services. The Department has reviewed your eligibility for all long-term care service programs. OAR 411-015-0015, 411-320-0080, 411-034-0000 through 411-034-0070

10. Does not meet In-Home program scope rule

You are not eligible for in-home support services as you are living in a [provider owned or provider rented dwelling] and your name is not on the deed, mortgage or title to the property. Your in-home support services are therefore being closed. The Department has reviewed your eligibility for all long-term care service programs. OAR 411-050-0405, 411-030-0033, 411-034-0000 through 411-034-0070

11. Failure to participate in annual service assessment

We requested that you participate in an assessment for your annual review on mm/dd/yy.  We have also made attempts to schedule this assessment with you. We have been unable to meet with you to complete your assessment. The applicant or their representative has the responsibility to participate in and provide information necessary to complete assessments within the time frame requested by the Department. OAR 411-015-0008, 461-115-0020, 461-180-0085, 461-115-0190

12. Failed to provide information for service assessment

We requested information from you on mm/dd/yy. The time frame to submit this requested information expired on mm/dd/yy. We have not received information necessary for your review. The applicant or their representative has the responsibility to provide information necessary to complete assessments within the time frame requested by the Department. OAR 411-015-0008, 461-115-0020, 461-115-0190, 461-180-0085

13. Left AFH or RCF and the client is not receiving other in-home services.

It has been reported that you voluntarily left [facility name] and are living in a residence that is not Medicaid-contracted.  The Department is unable to pay a non Medicaid-contracted provider.  You are also not receiving in-home support services. As you are not receiving any waivered services, your service plan is being closed. The Department has reviewed your eligibility for all long-term care service programs. OAR 411-027-0000; 411-027-0025; 411-030-0020 through 0070; 461-160-0560; 461-180-0040; 461-135-0750, 411-034-0000 through 411-034-0070

14. Closure of Spousal Pay Program due to natural supports

You are not eligible for Spousal Pay Program services because your natural support system is able to meet all of your assessed service needs. This decision is based on the information gathered during your assessment and interview with you on mm/dd/yy. Payments for Spousal Pay services are not intended to replace the resources available to an individual from their natural support system. The Department can only authorize payment when natural support is unavailable, insufficient or inadequate to meet your service needs. The Department has reviewed your eligibility for all long-term care service programs. OAR 411-015-0000 through 411-015-0015; 411-027-0000; 411-030-0002 through 411-030-0080, 411-034-0000 through 411-034-0070

15. No longer an Oregon resident

In order to receive services in Oregon you must be living in Oregon. According to our information you no longer reside in Oregon. OAR 461-120-0010

1. Not OSIPM eligible

Note: If the OSIPM eligibility is based on receipt of services, send a separate 540 to deny medical.

2. Failure to employ an enrolled HCW

Note: If the OSIPM eligibility is based on receipt of services, send a separate 540 to deny medical.

You have requested in-home support services but have not hired and established a start date for an enrolled Homecare Worker or Contracted In-Home Agency. Initial eligibility for in-home services cannot begin until you have identified an enrolled provider and scheduled a start date for services. The case manager must prior authorize this plan. You have not met this requirement within 45 days. OAR 461-115-0190, 461-180-0040, 461-135-0750

3. Client does not meet SPL requirements

Note: If the OSIPM eligibility is based on receipt of services, send a separate 540 to deny medical.

You are not eligible for long-term care services because your needs in activities of daily living do not meet the criteria to be eligible for waivered services. The Department currently serves individuals with a service priority level 1 through 13. You have been assessed as a service priority level [xx]. This decision is based on the information gathered during the interview and assessment on mm/dd/yy. The Department has reviewed your eligibility for all services and have found you to be ineligible. OAR 411-015-0000 through 411-015-0015, 411-015-0100, 411-034-0000 through 411-034-0030

4. Service needs related to mental or emotional disorder (MH)

You are not eligible for long-term care services because your natural support system is meeting all of your assessed service needs. This decision is based on the information gathered during your assessment and interview on mm/dd/yy. The Department can only authorize payment when natural support is unavailable, insufficient or inadequate to meet your service needs. Your natural support system is adequately meeting your service needs. The Department has reviewed your eligibility for all services. OAR 411-015-0000 through 411-015-0015; 411-027-0000; 411-030-0002 through 411-030-0070, 411-034-0000 through 411-034-0030

6. Not eligible for SPPC due to not needing assistance in Personal Care Services

9. Exceptional Care Plan Rate

Your request for a long-term care service plan of [xx] hours at a cost of $_____ per month is denied. The service plan is based on your assessed service needs. The case manager has completed your assessment and it does not show the need for [insert #] hours of care. You have [natural supports, assistive devices, home modifications, other service options that are more cost effective] that have been considered in determining the service hours authorized in your plan. This decision is based on the information gathered during your assessment and interview with you on mm/dd/yy.  You are approved for a service plan of [insert #] hours at a total cost of $_____. OAR 411-027-0000 through 411-027-0050; 411-015-0000 through 411-015-0008; 411-030-0002; 411-030-0020 through 0070

10. Spousal Pay- does not meet spousal pay rules

Note: If the OSIPM eligibility is based on receipt of services, send a separate 540 to deny medical.

To be eligible for the Spousal Pay Program, you must have a progressive, debilitating disease or spinal cord injury with permanent impairment. You must also require full assistance in four of the six activities of daily living (mobility, eating, cognition, dressing/grooming, bowel/bladder/toileting, and bathing/hygiene).  You do not meet this criteria as [you do not have a progressive, debilitating disease or spinal cord injury with permanent impairment OR you do not require full assistance in four of the six activities of daily living]. This decision is based on the information gathered during your assessment and interview with you on mm/dd/yy. You are not eligible for the Spousal Pay Program. OAR 411-030-0080, 411-030-0020, 411-015-0006, 411-015-0008, 411-030-0050, 411-015-0100

11. Does not meet in-home program scope rule

Note: If the OSIPM eligibility is based on receipt of services, send a separate 540 to deny medical.

You are not eligible for in-home support services as you are living in a [provider owned or provider rented dwelling] and your name is not on the deed, mortgage or title to the property. Your application for Home and Community Based Services is denied. The Department has reviewed your eligibility for all long-term care services. OAR 411-050-0405, 411-030-0033, 411-034-0000 through 411-034-0070

12. Failure to participate in service assessment

We requested that you participate in an assessment for your on mm/dd/yy.  We have made attempts to schedule this assessment with you. We have been unable to meet with you to complete your assessment. The applicant or their representative has the responsibility to participate in and provide information necessary to complete assessments within the time frame requested by the Department. OAR 411-015-0008, 461-115-0020, 461-115-0190, 461-180-0085

13. Failed to provide information for service assessment

We requested information from you on mm/dd/yy. The time frame to submit this requested information expired on mm/dd/yy. We have not received the information. The applicant or their representative has the responsibility to provide information necessary to complete assessments within the time frame requested by the Department. OAR 411-015-0008, 461-115-0020, 461-115-0190, 461-180-0085

1. Reduction of service hours due to decrease in care needs

Your ability to meet your activities of daily living has improved.  This decision is based on the information gathered during your assessment and interview performed on mm/dd/yy.  You no longer require [insert level of assistance(s)] with [insert ADL(s)].  Your in home service plan will be reduced by [xx] hours per month to reflect that you no longer require help in these areas. The total number of care plan hours you will receive is [xx] hours per month effective mm/dd/yy. OAR 411-015-0005 through 411-015-0100; 411-030-0020 through 411-030-0070

2. Live-in HCW working outside the home

The live-in Homecare Worker you have employed can no longer be paid to provide live-in services. Live-in Homecare Workers must be available to address the service needs of clients throughout a twenty-four hour period. A Homecare Worker who works a job outside the client’s home or building is not considered available to meet the service needs of the client. Your Homecare Worker is employed outside your home. Your in-home service plan will be reduced to [xx] hours per month as an hourly services plan with your current provider. OAR 411-030-0002 through 411-030-0070

3. Reduction of service hours due to natural supports

Your authorized hours for in-home support services will be reduced from [xx] to [xx] hours because your natural support system is meeting some of the following service needs [insert activities]. The Department can only authorize payment when natural support is unavailable, insufficient or inadequate to meet your service needs. This decision is based on the information gathered during your assessment and interview with you on mm/dd/yy. OAR 411-015-0000 through 411-015-0015; 411-030-0002 through 411-030-0070; 411-027-0000

5. Reduction in SPPC hours due to reduced personal care needs

Your authorized hours for State Plan Personal Care Services will be reduced from [xx] to [xx] hours because your ability to meet your needs in [insert ADL(s)] has improved. This decision is based on the information gathered during your assessment and interview with you on mm/dd/yy.  OAR 411-034-0000 through 411-034-0070

6. Reduction in SPPC hours due to natural supports

Your authorized hours for State Plan Personal Care Services will be reduced from[xx] to[xx] hours because your natural support system (family, friends, neighbors or community resources) is providing assistance with the following needs: [insert activities]. The Department can only authorize payment when natural support is unavailable, insufficient or inadequate to meet your service needs. This reduction is based on the information gathered during your assessment and interview with you on mm/dd/yy .  OAR 411-034-0000 through 411-034-0070

7. Spousal Pay-Reduction based on natural support

Your authorized hours for Spousal Pay Program services will be reduced from[xx] to[xx] hours because your natural support system is available to meet some of the following service needs [insert activities]. Payments for in-home support services are not intended to replace the resources available to an individual from their natural support system. The Department can only authorize payment when natural support is unavailable, insufficient or inadequate to meet your service needs. This decision is based on the information gathered during your assessment and interview with you on mm/dd/yy. OAR 411-015-0000 through 411-015-0015; 411-027-0000; 411-030-0002; 411-030-0020 through 411-030-0080

8. Service transportation reduction- rides reduced
(contracted transportation provider)

Service transportation can only be authorized for reasons related to an individual’s safety or health when other resources, such as natural supports, volunteer transportation, or mail order and delivery, are not available. Your eligibility for service transportation was reviewed as a part of the recent assessment conducted with you on mm/dd/yy. Based on Oregon Administrative Rules, rides to the following locations can no longer be provided: [insert location]. Therefore, the number of rides authorized per month through [transportation provider name] is being reduced from[xx] rides to[xx] rides per month. OAR 411-030-0020, 411-030-0055, 411-030-0070

10. Increase in pay-in for in-home support services 

Use the SDS 540P

Note: Don’t forget that home delivered meals is calculated as part of the client’s pay in, so if the meal costs go up, then a 540P should be sent to notify of increased pay-in.

11. Increase in liability for CBC facility or NF

Note: For NF, the 458A from the DHS Forms Server can serve as an adequate notice (the OA version does not unless rule numbers and hearing rights are included)

You are responsible for making a contribution to the cost of your long-term care services. This amount has increased due to a [increase in your income, cost of living increase, decrease in the amount diverted to your spouse, etc]. The new amount of you liability is $__________. OAR 461-160-0610, 461-160-0620