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APD Client Pay-In

This guide is not policy. It is intended to help workers understand the Client Pay-In system for OSIP(M) clients receiving home and community based care services.

Updated 5/19/2017


dot Pay-In Cookbook dot
 

See example for Spousal Pay pay-in calculation.
 

  What is the Pay-In?

Home and community based care services provided by APD to enable clients to remain as independent as possible.

"Home and community based care” includes in-home services ( including Independent Choices and Spousal Pay), residential care facility services, assisted living facility services, adult foster care services, home-delivered meals (when provided in conjunction with in-home services), specialized living services and Adult Day services.

In-Home and Spousal Pay Program services utilize the Pay-In system.

A client is eligible for in-home or spousal pay program services if they meet non-financial and financial eligibility, and have a Service Priority Level within those being currently served per rule 411-015-0015 (according to the Assessment completed by a Case Manager) and other service criteria.

Clients who receive home and community based care or spousal pay program services and have countable income above the payment standard must contribute toward the cost of their service, unless they are not required to pay under 461-160-0610. This is called the client liability. It is calculated by the Case Manager and then, when received from the client, recorded on the pay-in system.

The Pay-In system allows the Department to collect the client's liability and apply that money to the client's cost of service.

461-185-0050 - Client Pay-In System
411-015-0015 - Current Limitations

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  Cost of Service - What's Included, What's Not

What is included in the Cost of Service:

What's NOT included in the Cost of Service:

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  Income Excluded from the Pay-In

Be sure to look up policy on income when calculating the Client Pay-In. Some income can be excluded. Below you will find a few examples of just some of the excluded income:

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  Calculations, Deductions/Special Needs

Calculations

Clients who receive home and community based care or spousal pay program services and have income above the income standard must pay either:

Clients pay whichever of the above is least costly to them.

See Deductions for Examples of Calculated Client Pay-In's with different types of deductions.

Michael Peters : Example A

Michael Peters has SSD income of $1880.00 per month. He does not work, has no additional medical costs or special needs, and there is no calculated LDS. His wife provides his care under the Spousal Pay Program. The cost of these services is $590.86 per month. A CEP also provides assistance with bathing two times each week. The cost of these services is $95.30 per month. There are no other medical costs or special needs.

 

SSD Income
$1880.00
OSIP Standard
-$1235.00
Calculated Pay-In:

$645.00


OR

Spousal Pay Program Services
$590.86
House Keeper Services
+$95.30
FICA (see worksheet example)
+$52.49
BFA (see worksheet example)
+ $1.08
Total Cost of Service:

$739.73

  • Note: In order for the CAPS Pay-In Worksheet to correctly calculate the client pay-in, you MUST set up an APD In-home benefit with one or more of the following services selected in the plan:
    • In-Home Care (HCW) Hourly or Live-in or Spousal Pay
    • In-Home (HK or PC) Agency Contract

The selection of one of these services will accurately determine the cost of each home and community based care service, including the FICA and the WBFA.

  • Note: It is not necessary to complete any manual calculations to determine client liability for spousal pay program cases. The ACCESS Pay-In calculation automatically accounts for differences in spousal pay related to self-management tasks and 24 hour availability.

In this case, the Calculated Pay-In is the smaller amount. Therefore $645.00 is the client liability.

  • Note: The client is responsible to pay his/her liability on a monthly basis.

 

Maggie Smith: Example B

Maggie Smith has SSD of $1320.00 per month. She does not work, and she has no medical costs or special needs. She receives Home Delivered Meals and Housekeeper services.

Note: In order to get the Home Delivered Meals to appear on the Pay In Worksheet, you must enter the service of Home Delivered Meals in the CAPS service plan.

 

SSD Income
$1320.00
OSIP Standard
-$1235.00
Calculated Pay-In:

$85.00


OR

Housekeeper Service
$308.21
Home Delivered Meals
$157.20
FICA (see worksheet example)
$23.58
BFA (see worksheet example)
+ $0.63
Total Cost of Service:

$489.62

  • Note: In order for the CAPS Pay-In Worksheet to correctly calculate the client pay-in, you MUST set up an APD In-home benefit with one or more of the following services selected in the plan:
    • In-Home Care (HCW) Hourly or Live-in or Spousal Pay
    • In-Home (HK or PC) Agency Contract

In this case, the Calculated Pay-In is the smaller amount. Therefore $85.00 is the client liability.

  • Note: The client is responsible to pay his/her liability on a monthly basis.

 


Deductions

There are several types of deductions that may reduce a client's liability. They are:

Below you will find examples of each type of deduction.

Earned Income Deductions

Maggie Smith: Example C

Maggie Smith has SSD of $1220.00 a month. She works and earns and average of $172.00 a month. She has no medical costs or special needs. She receives Home Delivered Meals and Housekeeper services.

 

SSD Income
$1220.00
 
Earned Income
+$172.00
 
Total Income
$1392.00
Earned Income Deduction
-$65.00
 
Adjusted Income
$1327.00
OSIP Standard
-$1235.00
 
Calculated Client Pay-In
$92.00

Her total cost of service is $489.62 (see Example B for details). Since her calculated pay-in, after deductions, is smaller than the cost of service, she pays the calculated pay-in rather than her cost of service.

  • Note: The client is responsible to pay his/her liability on a monthly basis.

 

OIM (Other Incurred Medical) Costs- (not covered by the client's medical card or 3rd party insurance)

For a client receiving home and community based care, the liability is the service cost ("cost of service" or "minimum liability") or the adjusted income of the client, whichever is less. 461-160-0620  j. A.

Post eligibility deductions are used prior to assigning a liability. If the client has an OIM deduction, it is applied prior to comparing the cost of service or their remaining income. The liability would be whichever is less.


    Maggie Smith: Example D

Maggie Smith has SSD of $1420.00 a month. She does not work. She has other incurred medical costs for Naturopathic medicine prescribed by her doctor. She receives Home Delivered Meals and Housekeeper services.

SSD Income
$1420.00
 
OSIP Standard
-$1235.00
 
Calculated Pay-In before deduction
$185.00
Prescribed Naturopathic Medication
-$68.50
 
Calculated Pay-In after deduction
$116.50

Her total cost of service is $489.62 (see Example B for details). Since her calculated pay-in after the OIM deduction is the smaller than the cost of service, she pays the calculated pay-in rather than her cost of service.

  • Note: The client is responsible to pay his/her liability on a monthly basis.

 

 


    Maggie Smith: Example E

Maggie Smith has SSD of $1420.00 a month. She does not work. She has other incurred medical costs for Naturopathic medicine prescribed by her doctor, and a monthly payment for new dentures. She receives Home Delivered Meals and Housekeeper services.

SSD Income
$1420.00
 
OSIP Standard
-$1235.00
 
Calculated Pay-In before deduction
$185.00
Dentures
-$150.00
 
Prescribed Naturopathic Medication
-$68.50
 
Calculated Pay-In after deduction
$0.00

Her total cost of service is $489.62 (see Example B for details). Since her calculated pay-in after the OIM deductions is $0.00, she has no pay-in.

  • Note: In this example the calculated pay-in is actually less than $0.00. When the calculated pay-in is less than $0.00 the Pay-in Worksheet will display $0.00 as the calculated pay-in.

 

 

OHI (Other Health Insurance) Costs


    Maggie Smith: Example F

Maggie Smith has SSD of $1380.00 a month. She does not work. She has a Medicare supplement. She receives Home Delivered Meals and Housekeeper services.

SSD Income
$1380.00
 
OSIP Standard
-$1235.00
 
Calculated Pay-In before deduction
$145.00
Medicare Supplement
-$120.00
 
Calculated Pay-In after deduction
$25.00

Her total cost of service is $489.62 (see Example B for details). Since her calculated pay-in after the OHI deduction is smaller than the cost of service, she pays the calculated pay-in rather than her cost of service.

  • Note: The client is responsible to pay his/her liability on a monthly basis.

 

 

Special Needs

 


    Maggie Smith: Example G

Maggie Smith has SSD of $1360.00 a month. She does not work. She has no medical costs. She is eligible for a laundry allowance and a telephone allowance as special needs. Because she owes a liability, the Department will not issue special needs checks, but instead, lower the liability amount. She receives Home Delivered Meals and Housekeeper services.

SSD Income
$1360.00
 
OSIP Standard
-$1235.00
 
Calculated Pay-In before deduction
$125.00
Laundry Allowance
-$10.00
 
Telephone Allowance
-$20.00
 
Calculated Pay-In after deduction
$95.00

Her total cost of service is $489.62 (see Example B for details). Since her calculated pay-in after the Special Needs deduction is smaller than the cost of services, she pays the calculated pay-in rather than her cost of service.

  • Note: The client is responsible to pay his/her liability on a monthly basis


    Maggie Smith: Example H

Maggie Smith has SSD of $1260.00 a month. She does not work. She has other incurred medical costs for an insurance supplement and she is eligible for a special diet allowance as special needs. She receives Home Delivered Meals and Housekeeper services.

SSD Income
$1260.00
 
OSIP Standard
-$1235.00
 
Calculated Pay-In before deduction
$25.00
Special Diet
-$50.00
 
Insurance Supplement
-$122.50
 
Calculated Pay-In after deduction
$0.00

Her total cost of service is $489.62 (see Example B for details). Since her calculated pay-in after the OIM deductions is $0.00, she has no pay-in.

  • Note: When a client has a pay-in of $0.00 and there are special needs on the case (in this example there is a special need for a special diet), the client is entitled to a cash payment for the special need. Issue the full amount of the special need payment. In this example, the client should receive a $50 monthly payment.

 

Anticipated Costs

Anticipated costs are expenses that the client can be reasonably expected to pay each month. These are usually ongoing and coded as OIM or OHI over the certification period. These may include: monthly insurance premiums, including Medicare Part D premiums above the benchmark; co-pays for provider visits; supplies.
These costs should be reviewed and reconciled at each redetermination.

The Medicare Part D need/resource code (Medicare Drug Costs or MDC) will be used to process Medicare Part D-covered drugs that are not on the plan formulary. For clients who have a stable list of prescription drugs, these costs can be anticipated over a six-month period only and will need to be reviewed and reconciled every six months.  Workers will need to code a six month end date on the MDC code.

5. Unanticipated Costs

Unanticipated costs are costs that cannot be reasonably anticipated, such as an emergency trip to the doctor or hospital. These can also include costs that are sporadic and may vary greatly in amount.

The receipts for these costs need to be turned in the month the cost occurs and should be applied to the liability in the month that they occur.

Form SDS 540M will be used for clients who report medical costs monthly. This form serves as a 10-day notice because it notifies the client of the increase and reduction in benefits. The form can also be used for clients with anticipated costs for up to a six month period but a separate notice is required to approve and end the deduction if it will last more than one month (remember to send a reduction notice to the client in the sixth month for the anticipated costs, as they will not receive the deduction after the sixth month, unless they can show the anticipated costs for the next six months).

Beginning in March 1, 2006, claims cannot be applied to the liability retroactively to any preceding calendar month(s) during which the costs were incurred, unless there are extenuating circumstances that prevent the client from providing receipts in the month the cost was paid such as being in the hospital.  Use reasonable judgment when looking at these situations.

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  Pay-In Worksheet and SDS 450 Liability Worksheet

1. Pay-In Worksheet

The Pay-In worksheet lists out the total, countable, adjustable and available income for the client. It will also list out the total cost of the home and community based care and the monthly pay-in amount for the client.

This worksheet pulls information from within the Oregon ACCESS case, and is only available within Oregon ACCESS.

The Pay-in Calculation Worksheet may be printed for the Primary Applicant. The case manager must have marked the client to be "Primary Applicant" for both Medical Assistance and Services in the Case Overview tab in the Benefits section of Oregon ACCESS. The client must also be receiving in-home services.

In order for the worksheet to pull data, there must be a Medical Expense type of "Client Pay-In" selected in the Medical Cost tab within the Oregon ACCESS case. The monthly pay-in amount no longer auto-fills into this field. The only way to view the pay-in is through the print preview of the CAPS Pay-in Worksheet form.

Allowable deductions must also be entered into the appropriate area of Oregon ACCESS for the information to pull to the worksheet. In addition, if a selection is from the Medical Cost tab, the "Allowable Med. Deduction" checkbox must be checked to pull to the worksheet.

If the client is blind, and the income standard for the blind is used, a Program code of either 3 or B3 must be selected on the Medical Assistance tab in the Benefit section of the case, or the worksheet will not apply the correct payment standard to the calculations, which will cause an error in the pay-in amount.

The Pay-in Worksheet will calculate correctly only if all needed information is entered. The worksheet will follow these steps:

2. SDS 450 Liability Worksheet

Case Managers will not fill in this form directly. This form will auto fill all fields when used from ACCESS. To calculate the clients liability by hand, the form can be found on the forms server.

View the blank SDS 450

To print the SPD 450 you must indicate the client is a "Primary Applicant" applying for Medical Benefits on the Medical Assistance tab in the Benefits Section of the Oregon ACCESS case.

The SPD 450 will follow the steps below to calculate the liability:


Step 1:
Recipient Income


Sections A-C This section of the form will print the total of any income entered on the "Income" tab, "Financial" section, of the ACCESS application. Any property or employment displayed on this screen will also print in this section of the form.
Section D The standard earned income deduction will automatically be deducted based on the program code selected in the "Benefit" section of the application.
Section E This information will come from the "Income" tab of the application, if an "Income Type" of "Plan for Self Support" is selected.
Section F If the client is in a nursing home, the $60.18 personal allowance will be deducted. For a home and community based care client, the correct need standard will be automatically deducted. This will be based on the provider selected on the service needs tab.
Section G Any trust costs identified on the Other Needs tab in the medical section of the application will be deducted here.
Recipient Adjusted Income
Section H Adjusted income will be calculated based on the client’s total income minus any allowable deductions.


STEP 2:
Community Spouse Income Allowance Computation:

Section A The Spousal allowance standard will automatically be entered at this step in the calculation.
Section B Shelter expenses entered on the "Shelter Cost" tab in the "Food Stamp" section of the application will print in this area of the form.

 

NOTE: The shelter expenses will only print if it is indicated the spouse is the "Primary Payor" or "Other Payor". If shelter costs are a mortgage payment and taxes and fire insurance are being paid, this information will come from the "Property" tab in the "Financial" section of the application. The total of the shelter costs will automatically be added together and entered as a total shelter amount. The standard shelter allowance will be deducted from the total shelter expenses and the remainder will be indicated at the Total allowance. The total allowance will then be added to the Community Spouse Standard for a SUBTOTAL shelter expense.

 

Section C Any income entered on the income tab that is identified as the spouse’s will be totaled and entered in this section of the form. This amount will be deducted from the subtotal and will be the TOTAL Community Spouse Income Allowance.


STEP 3:
Dependent Income Allowance Computation (with spouse):

Section A The Dependent allowance standard will automatically be entered at this step in the calculation.
Section B This step will total all eligible person(s) on the application who have been given the role of "Dependent" (and shown as living with the Primary Applicant). This information will come from the "Persons in the Application for..." screen at the beginning of the ACCESS application.
Section C The SUBTOTAL will automatically multiply the total number of eligible dependents by the dependent allowance standard and enter the amount here.
Section D This line will total any income entered on the income tab that belongs to the dependent(s).
Section E The dependents total income will be deducted from D (Recipient income) above and be the SUBTOTAL.
Section F One third of Section E will automatically be calculated and entered on this line.

 

NOTE: If there is no spouse, this figure will be calculated based on the total number of eligible dependents, plus the primary applicant.

 


STEP 4:
List Deductions Allowed From Recipient Income:

Section A This is the community spouse income allowance from step 2.
Section B This is the dependent income allowance from step 3.
Section C This could be the possible total Income Diversion to spouse (LDS). It is the total of the spouse income allowance (line 4a) plus the dependent income allowance (line 4b).
Section D The LDS amount is entered here. It is the "possible total income diversion" compared with the client’s adjusted gross income. The smaller of the two is automatically entered here.
Section E The cost to maintain a home comes from the Benefit section, Service tab, Shelter Exception field. The amount entered in this field will be added as applicable.
Section F The uncovered medical expenses come from the premium amount for any health insurance indicated on the health insurance screen and from a medical cost identified as Other Incurred Medical from the medical cost tab in the food stamp section of the application.
Section G The total recipient deduction is the total of the LDS amount, cost to maintain a home, plus any uncovered medical expenses.


STEP 5: Recipient Liability Amount:

This amount is calculated automatically. This is the amount that the client pays monthly to the facility in addition to room and board.

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  Payments, Adjustments & Refunds

Payments

Clients receiving home and community based care or spousal pay program services with income above the SSI standard are required to pay a liability. Payments are based on prospective budgeting, and are due at the beginning of the month. Payments must be made in the month that they are due.

Clients will receive a computer generated billing notice at the beginning of the month telling them the date the payment is due, and the amount due.

If the client does not pay the total liability by the end of the month, the client is not eligible for the services that were received in that month (461-160-0610).

The Services Termination Notice serves as a timely continuing benefit notice. However, the case manager must also send a closure notice (SDS 540) informing the client of any other Medicaid benefits the client may be eligible for per rule 461-175-0230. The case will not close automatically, so it is the responsibility of the caseworker to close the case via CAPS and CMS, with effective dates of the end of the month. This action needs to be taken before CMS cutoff. If the case is closed before CMS cutoff and the client comes in and pays their liability after CMS cutoff and prior to the end of the month, use a Restore to reopen the CMS case, and Approve a new CAPS Service Benefit/Plan ensuring there is no gap in the eligibility dates. The CAPS service benefit/plan begin date will be the day after the benefit/plan was previously ended. For example, if the CAPS Service Benefit/Plan ended on 9/30/09, enter a begin date of 10/01/09. Keep the original review date on CMS and CAPS. For CAPS, no changes will need to be made to the assessment "Review Before" date unless it was formerly changed due to the closure of services.

Late Payments

If the liability payment is not received by the 15th of the month, a computer-generated "Services Termination Notice" will be sent to the client. This notice will include the date payment was due, the amount overdue and when services will end. This notice includes rule numbers and hearing rights as well as the case manager's office information and phone number.

Along with the "Services Termination Notice" that is sent to the client, a computer-generated notice, “Payment Authorization Termination Notice”, is sent to the homecare worker (HCW). This notice explains that the client may not be eligible to receive in home services and whom the HCW should contact to find out if the client is eligible to receive in-home care.

Clients must pay the liability in the month that it is due. Payments received the following month are not to be used for any retroactive payment. The liability for the month that was not paid needs to be adjusted off. The client will need to pay the liability for the current month to receive services again.

Partial Payments

If the client makes a partial payment in the month the liability is due, but does not pay the full liability by the end of the month, the Department will not accept the late portion of payment. The remaining liability amount that is due will need to be adjusted off. The client will need to pay their current calculated liability for the current month to receive services again.

Ending Services for Non Payment

The Services Termination Notice serves as a timely continuing benefit notice. However, the case manager must also send a closure or reduction notice (SDS 540) informing the client of any other Medicaid benefits the client may be eligible for per OAR 461-175-0230.

The case will not close automatically, so it is the responsibility of the caseworker to close the case via CAPS and CMS, with effective dates of the end of the month. This action needs to be taken before CMS cutoff.  End the Service Benefit and Plan that was associated with the assessment. This is the only CAPS transaction needed to end the Service Benefit and Plan. No status changes need to be completed to the assessment portion of CAPS to close the assessment.
 
If the case is closed before CMS cutoff and the client comes in and pays their liability after CMS cutoff but prior to the end of the month, use a Restore to reopen the CMS case and Approve a new CAPS Service Benefit/Plan ensuring there is no gap in the eligibility dates. The CAPS Service Benefit/Plan begin date will be the day after the benefit/plan was previously ended. For example, if the CAPS Service Benefit/Plan ended on 9/30/09, enter a begin date of 10/01/09. Keep the original review date on CMS and CAPS. For CAPS, no changes will need to be made to the assessment ‘Review Before’ date unless it was formerly changed due to the closure of services.

Overpayments

For any month the client does not pay the full amount of their liability, an overpayment needs to be referred to the Overpayment Writing Unit (OWU). The overpayment is calculated for the month that the liability payment was not made in full. The overpayment amount includes:

Use the SDS 284R to refer cases with a client error (CE) overpayment.

For instructions on completing an overpayment referral see SPD Generic program
elements G. Overpayment Recovery #2

Reopening Case that was Closed due to Failure to Pay the Liability

A client must establish a new date of request (DOR) after the case has been closed due to failure to make the liability payment (461-115-0030).  If the DOR is made before the end of the month following the month of case closure, a new application is not required (461-115-0050).  The Eligibility Worker determines whether the case can be reopened without a new application or if there have been enough changes so that a new application is required.  If the DOR is later than the month following the month of case closure, a new application is required.  Once the client has again been determined eligible, benefits begin from the DOR as long as the client was eligible on that date, the same as for any other new applicant (461-180-0090).  The client is not eligible prior to the date that the service plan is authorized for the home care worker (461-180-0040).  This may cause benefits to be prorated in the reopen month.

 

Although the client usually has the entire month to make the liability payment (461-185-0050), you may pend a case when the client has previously failed to make the pay-in for proof of payment before reopening the case.  OAR 461-115-0610 requires that in order to be eligible for benefits, clients must provide verification when the Department requests verification.  In addition, OAR 461-115-0700 requires that eligibility factors must be verified at application when eligibility for benefits is questionable.  When a client has previously failed to make the pay-in, it is questionable that they will make the pay-in during the month that the case will reopen.  Therefore you may pend the case for proof that the liability payment has been made to verify that the client is again eligible for in-home services, prior to reopening the case.

 

Adjustments

Adjustments may be made when clients are reducing their liability with allowable deductions or when the client has not paid their liability.

Adjustments or Refunds after the liability has been moved to the Appl Serv column:

If an adjustment or refund needs to be made after the liability that was paid has moved from the Bal Serv column to the Appl Serv column, workers will need to mail or fax a Reverse Collection request that include the caseworker and supervisor approval signatures to:

OFS/DHA Receipting
Attn: Client Pay-In Technician
500 Summer St NE E-08
Salem, OR 97301
Fax: 503-378-2806

Automated Pay-in Refund Process

Refunds are processed from Central Office. They are not processed in the branch offices.

The Client Pay-In System will automatically refund unused money. It takes about three months for the majority of the claims to be paid. After this period of time, the system will
automatically move the service balance to the over collected balance by creating an adjustment.

If the refund balance amount is over $5.00 a refund will be generated. If the balance is under $5.00 the amount will be held and checked during the next monthly cycle. This process will occur in the middle of each month. The system processes excess service balances for months that are more than three months past. Amounts under $5.00 can be manually refunded by Central Office staff in necessary.

The system will run the refunds the second week-end of every month. The following week, the refund checks will be mailed along with an Over Collection Refund Notice (SDSD 1400B).

A report will be produced that shows all the refunds that are made. The report is SJF0270R-A Over Collection Refund. It is available on View Direct.


If a client needs a refund outside of the automatic run cycle (for example, an amount paid in error), contact the Help Desk.

Clients Ineligible Due to Lack of home and community based care services

A report was developed that lists clients that appear to be ineligible
because they have not received any home and community based care services. This report is SJF0810R-A Potentially Ineligible Client - No home and community based care services Received.

The report is produced when the automated refunds are processed and the system
detects that the full pay-in amount is being refunded, and that the client did not have any charges for home and community based care services. This report is available on View Direct.

Local office may wish to check this report periodically.

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  EPD and the Pay-In System

The Pay-In System cannot be used for EPD clients. EPD service clients are not in the Pay-In system. If a client is working and chooses not to be in or is not eligible for EPD, they may have a liability. If they are not in EPD, they must be in the Pay-In system. EPD clients will pay a Participant Fee (see 461-160-0800) but will not have a liability, even if they are receiving in-home services or are in the ICP program.  For more information about the EPD program, see OSIP WG.11.

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  State Plan Personal Care (SPPC) and the Pay-In

Since State Plan Personal Care is not a waivered program, there is also no pay-in for State Plan Personal Care cases. Most State Plan Personal Care clients are SSI eligible and qualify for OSIPM. Those that are OHP eligible will often have income over the SSI standard with income up to 185% of the federal poverty level. However, even those OHP clients with income over the SSI standard will not have a pay-in, since State Plan Personal Care is not a waivered service. Any State Plan Personal Care case set up on the pay-in system is an error and will also result in unnecessary payments by the client and subsequent refund back back to the client.

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  Resources

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  Administrative Rules

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  System Generated Notices

There are several different notices that are system generated that will be sent out to the client's and the providers

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  Frequently Asked Questions

If you have questions about client pay-in policy or procedures, please send an email to michael.g.avery@state.or.us. These questions may be posted anonymously on the site if others might benefit.


(The following questions were updated 07/1/11)

How do I get a copy of the system generated notices that the client and HCW were sent?

If there is a Service Balance from the last month, can that balance be applied to the current month, or will the balance be refunded?

Is it alright to zero out the pay-in if the services start in the middle of the month and the client has spent their funds?

If the client has paid the wrong amount is it okay to zero out the remaining liability if it is under $5.00 to keep the case from suspending?

 


(The following questions were updated 10/20/05)

Can a client get a refund?

Can I process a refund?

When can my client expect a refund?

Can I request a refund for my client earlier than normal processing times for special circumstances?

What if my client pays in advance?

What if my client dies and there is unused money in the account?

What if my client moves out of their home, into a facility and there is unused money in the account?

How can I tell if my client received a refund?

How can I tell if my client may be potentially ineligible on the pay-in system?

Why can’t I issue a voucher for my client?

Can a voucher be forced if the client is ineligible?

My client started services effective the beginning of the month but I was not able to get their liability started on the pay-in system, can I receipt the money into the pay-in system?

How do I receipt the money in then?

How do I decrease or increase the pay-in liability on the current month?

If my client’s case is closed or they die, will the provider still be paid if I close or death out the case?

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  Transmittals

Transmittal #

Date

Title

APD-IM-17-045 05/17/17 Info: Discontinuance of Recurring Payment Option
APD-IM-17-041 05/09/17 Info: Online Payment Option for In-Home Individuals with a Pay-in
SPD-IM-12-039 06/26/12 Info: Debit/Credit Card Payment Option (new)
SPD-IM-09-049 06/09/09 Info: Overpayments for Failure to Pay the Entire Liability in the Pay-In System
SPD-AR-08-045 07/03/08 Action: July 2008 Cost of Living and Pay-in Notices: Homecare Worker Wages, Contracted In-Home Care Agency and Home Delivered Meals
SPD-AR-07-046 11/08/07 Action: Implementation of HCWs 2007-09 CBA: Client Pay-In and Paid Time Off
SPD-AR-07-032 07/31/07 Action: COLA Increases: Contracted In-Home Agencies and Home Delivered Meals
SPD-AR-07-001 01/03/07 Action: Pay-In System: Updates needed and future monitoring
SPD-IM-06-093 11/29/06 Info: COLA Increases and the Pay-In
SPD-PT-06-027 06/28/06 Policy: Cost of Living HCW Wage and Home Delivered Meals Rate Increases that Effect Client Pay-In
SPD-PT-06-011 02/28/06 Policy: Client Liability and Overpayments
SPD-PT-06-009 02/14/06 Policy: MMA Policy Clarification: Medicare Part D Other Incurred Medical Deductions
SPD-IM-05-079 10/06/05 Info: SPD Client Pay-In Web Page and Cookbook
SPD-IM-05-075 10/04/05 Info: New Case Management Web Site
SPD-PT-05-027 08/26/05 Policy: The Pay-In System and coding Spousal Pay Program and State Plan Personal Care
SPD-AR-05-031 05/19/05 Action: New address for Client Pay-In payments & receipts
SPD-IM-04-115 12/23/04 Info: FICA Tax Deductions for Spousal Pay Providers
SPD-PT-04-046 12/23/04 Policy: Homecare Worker Wage Increase and Client Pay-in Notices
SPD-IM-04-105 12/02/04 Info: Training Document: Sample Decision Notices for Home and Community Base Care Service Cases
SPD-PT-04-034 08/05/04 Policy: Home Delivered Meals
SPD-IM-04-052 06/23/04 Info: Client Pay-in Refund Check Processing
SPD-PT-04-020 05/07/04 Policy: Homecare Benefit Fund Assessment (BFA), FICA and Oregon ACCESS Pay-in Calculation/Worksheet changes
SPD-AR-03-029 09/09/03 Action: Homecare Worker Wage Increase, Client Pay-in and Timely Notices
IM-02-052 09/19/02 Info: Pay-in System Corrections to reinstate the Automatic Refund Process
EL-02-004 02/21/02 Info:  Reissue of Executive Letter 01-009, Pay-In System

EL-01-009

04/10/01

Info: Pay-In System

IM-00-94

09/19/00

Info: Excess Balance Pay-In Project

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  Glossary of Terms

Adjusted income. - Adjusted income is countable income minus deductions.

Cost-of-Service - The total combined cost of each service being provided to the client by a provider.

Excess Income - Earned or Unearned income that is over the OSIP standard.

In Home Support Services Definitions - 411-030-0020

Liability - Clients who do not receive SSI, but whose countable income is under the Countable Income Limit, must apply their adjusted income to reduce the cost of their care or service. This is their client liability.

Pay-In - The amount of the clients liability for In-Home care waivered services.

Service Priority/Clients Served Definitions - 411-015-0005

Home and community based care service - Services provided through Oregon’s Medicaid Home and Community-Based Services waiver which allow the state to provide home and community-based services to eligible clients in place of nursing facility care. Waiver services include in-home services, spousal pay program services, residential care facility services, assisted living facility services, adult foster care services, home-delivered meals (when provided in conjunction with in-home services), specialized living Services, Adult Day Services and Oregon’s Independent Choices Program.

 

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