This guide is not policy. It is intended to help workers understand the Consumer Pay-In system for OSIP(M) consumers receiving home and community based care services.
|What is the Pay-In?|
Home and community based care services (HCBS) provided by APD to enable consumers to remain as independent as possible.
HCBS includes in-home services (including the Independent Choices Program (ICP) and Spousal Pay (SP)), residential care facility (RCF) services, assisted living facility (ALF) services, adult foster home (AFH) services, home-delivered meals (HDM) (when provided in conjunction with in-home services), specialized living services and Adult Day services (ADS).
In-Home and SP services utilize the Pay-In system.
A consumer is eligible for in-home or SP services if they meet non-financial and financial eligibility, and have a Service Priority Level (SPL) within those being currently served per rule 411-015-0015 (according to the assessment completed by a case manager (CM)) and other service criteria.
Consumers who receive home and community based care (CBC) or SP 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 liability or pay-in. It is calculated by the CM and then, when received from the consumer, recorded on the pay-in system.
The Pay-In system allows the Department to collect the consumer's pay-in and apply that money to the consumer'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 and 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 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|
Consumers who receive home and community based care or SP program services and have income above the income standard must pay either:
Consumer pay whichever of the above is least costly to them.
See Deductions for Examples of calculated pay-in with different types of deductions.
Michael Peters : Example A
In this case, the calculated pay-in is the smaller amount. Therefore $586.00 is the pay-in.
Maggie Smith: Example B
Note: In order to get the HDMs to appear on the Pay-In Calculation Worksheet, you must enter the service of HDMs in the CA/PS service plan.
In this case, the calculated pay-in is the smaller amount. Therefore $26.00 is the pay-in.
Deductions/Medical Related Payments
Post eligibility deductions are used prior to assigning a pay-in. There are several types of deductions that may reduce a pay-in. They are:
Below you will find examples of each type of deduction.
Earned Income Deductions
- $65.00 standard deduction for those consumers that have earned income.
Maggie Smith: Example C
Maggie's total cost of service is $489.62 (see Example B for details). Since the calculated pay-in, after deductions, is smaller than the cost of service, the amount due would be the $33.00 calculated pay-in rather than the cost of service.
Medical Costs - (not covered by the consumer's medical card or 3rd party insurance)
For a consumer receiving HCBS, the pay-in is the cost of service or the adjusted income of the consumer, whichever is less. 461-160-0620 j. A.
If the consumer has a medical cost, it is applied prior to comparing the cost of service or their remaining income. The pay-in would be whichever is less.
- Prescription drugs and over-the-counter medications prescribed by a licensed practitioner, the annual fee for a drug prescription card, medical supplies and equipment, dentures, hearing aids, prostheses, and prescribed eyeglasses.
- DME such as walkers, wheelchairs, C-PAP etc.
- Medical and dental care, including psychotherapy, rehabilitation services, hospitalization, and outpatient treatment.
- The cost of a medical service provided by, prescribed by, or used under the direction of a licensed medical practitioner; or a medical necessity approved by the Department.
- Un-reimbursed medical expenses.
Maggie Smith: Example D
Total cost of service is $489.62 (see Example B for details). Since the calculated pay-in after the medical deduction is less than the cost of service, therefore, the calculated pay-in would be $57.50 owed rather than the cost of service.
Maggie Smith: Example E
- Receives SSD of $1420.00 a month.
- Does not work.
- Has medical costs for Naturopathic medicine in the amount of $68.50 prescribed by a doctor.
- Has a monthly payment for new dentures in the amount of $150.00.
- Receives HDMs and In-Home services.
SSD Income $1420.00 OSIP Standard + $500 -$1294.00 Calculated Pay-In before deduction $126.00 Dentures -$150.00 Prescribed Naturopathic medicine -$68.50 Calculated Pay-In after deduction $0.00
The total cost of service is $489.62 (see Example B for details). Since the calculated pay-in after the medical cost is $0.00, there is no pay-in due.
- 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 Calculation Worksheet will display $0.00 as the calculated pay-in.
Other Health Insurance Premiums
Health and hospitalization insurance premiums and coinsurance, (health insurance premiums paid less frequently than monthly are prorated over the period covered by the premium).
Maggie Smith: Example F
- Receives SSD of $1480.00 a month.
- Does not work.
- Has a Medicare supplement.
- Receives HDMs and In-Home services.
SSD Income $1480.00 OSIP Standard + $500 -$1294.00 Calculated Pay-In before deduction $186.00 Medicare Supplement -$120.00 Calculated Pay-In after deduction $66.00
The total cost of service is $489.62 (see Example B for details). The calculated pay-in after the deduction is smaller than the cost of service, therefore, the calculated pay-in would be owed rather than the cost of service.
- Note: The pay-in must be paid by the consumer by the end of the month.
Special Needs/Medical Related Payments (MRP)
Special needs payments are now called MRP and are no longer used as a deduction to reduce a consumer's pay-in. If a consumer has been approved for an ongoing special need, they will owe the full pay-in amount and be issued a MRP whether the calculated pay-in is $0.00 or not. Each MRP is issued as a separate payment to the consumer.
MRP types and special needs eligiblity criteria are covered in OPEN in the Medical Related Payments Chapter 2, Section 11 which begins on page 528. Additional information on requesting and issuing MRPs is outlined in the Program Payments and Supports QRG beginning on page 15.
See example G below:
Maggie Smith: Example G
Maggie will receive an ongoing MRP of $10.00 every month for the laundry allowance and a separate MRP of $20.00 every month for the supplemental communications allowance. The total cost of service is $489.62 (see Example B for details).
Anticipated costs are approved expenses the consumer can be reasonably expected to pay each month. These are usually ongoing and may include: monthly insurance premiums, including Medicare Part D premiums above the benchmark, co-pays for provider visits and supplies. Ongoing expenses entered into ONE should have an end date showing when payments are scheduled to end (if known) or match the renewal date to be reviewed and reconciled at each annual redetermination.
Unanticipated costs are costs that cannot be reasonably anticipated, such as an emergency trip to the doctor or hospital. This can also includes costs that are sporadic and may vary greatly in amount. Verification for these costs need to be turned in the month the cost was paid and should be applied to the liability in that month.
Costs cannot be applied to the pay-in retroactively unless there are extenuating circumstances that prevented the consumer from reporting 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 cost of the home and community based care services for the consumer.
This worksheet pulls information from the OA case, and is only available within OA.
The Pay-in Calculation Worksheet may be printed for the Primary Applicant. In order for the worksheet to pull data, there must be a Medical Expense type of "Client Pay-In" selected on the Medical Cost tab within the OA case. The monthly pay-in amount no longer auto-fills in this field. The pay-in can be viewed through the print preview of the CA/PS Pay-in Worksheet form. The consumer must also be receiving in-home services.
The Pay-in Worksheet will calculate correctly only if all needed information is entered.
2. SDS 450 Liability Worksheet
This form is NOT required unless specifically requested by the consumer when they don't understand the liability amount on the notice sent from ONE. It must be filled out manually and is used for Nursing Facility (NF) and Community Based Care (CBC) settings. The information needed to populate the fields on the 450 should match the information found in ONE. The form can be found on the forms server.
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|Payments, Adjustments & Refunds|
Consumers receiving home and community based care or SP program services with countable income above the SSI standard are required to pay a pay-in. 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.
Consumers 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 consumer does not pay the total pay-in by the end of the month, the consumer is not eligible for the services that were received in that month (461-160-0610).
The auto generated Services Termination Notice serves as a timely continuing benefit notice. The CM must send a services closure notice (SDS 540) informing the consumer of any service and other Medicaid benefits the consumer may be eligible for per rule 461-175-0230. The case will close automatically in ONE. The CM must close the Benefit and Service plan in CA/PS after or on the first of the next month. The CM must also send HCWs an SDS 4105 notice.
If the pay-in is not received by the 15th of the month, an auto generated "Services Termination Notice" will be sent to the consumer. This notice will include the date the payment was due, the amount overdue and when services will end. It also includes rule numbers and hearing rights as well as the local office information and phone number.
An auto generated notice, “Payment Authorization Termination Notice”, is sent to the homecare worker (HCW). This notice explains that the consumer may not be eligible to receive in-home services and whom the HCW should contact to find out if the consumer is eligible to receive in-home care.
Consumers must pay the pay-in the month it is due. Payments received the following month are not to be used for any retroactive payment. The pay-in for the month that was not paid needs to be adjusted off. The consumer will need to pay the pay-in for the current month to receive services again.
If the consumer makes a partial payment in the month the pay-in is due, but does not pay the full pay-in by the end of the month, the Department will not accept the late portion of the payment. The remaining pay-in amount that is due will need to be adjusted off. The consumer will need to pay their current calculated pay-in 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 CM must also send a closure or reduction notice (SDS 540) informing the consumer of any other Medicaid benefits the consumer may be eligible for per OAR 461-175-0230.
For any month the consumer does not pay the full amount of their liability/pay-in, an overpayment needs to be referred to the Office or Overpayment and Recovery (OPAR). The overpayment is calculated for the month that the pay-in payment was not made in full. The overpayment amount includes:
Use the SDS 284R to refer cases with a consumer error overpayment.
For instructions on completing an overpayment refer to OPEN "Overpayments" Chapter 3, Section 5.
Reopening Case that was Closed due to Failure to Pay the Liability/Pay-in
A consumer must establish a new date of request (DOR) after the case has been closed due to failure to make the pay-in 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 re-opened 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 consumer has again been determined eligible, benefits begin from the DOR as long as the consumer was eligible on that date, the same as for any other new applicant (461-180-0090). The consumer is not eligible prior to the date that the service plan is authorized for the HCW (461-180-0040). This may cause benefits to be prorated in the re-open month.
Although the consumer usually has the entire month to make the pay-in payment (461-185-0050), you may pend a case when the consumer 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, consumers must provide verification when the Department requests it. In addition, OAR 461-115-0700 requires that eligibility factors must be verified at application when eligibility for benefits is questioned. When a consumer 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 payment has been made to verify that the consumer is again eligible for in-home services, prior to re-opening the case.
Adjustments may be made when consumers are reducing their pay-in with allowable deductions or when the consumer has not paid their pay-in.
Adjustments or Refunds After the Pay-in has Been Moved to the Appl Serv Column:
If an adjustment or refund needs to be made after the pay-in 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 worker and supervisor approval signatures to:
Attn: Consumer Pay-In Technician
500 Summer St NE E-08
Salem, OR 97301
Automated Pay-in Refund Process
Refunds are processed from Central Office (CO). They are not processed in the local offices.
The Consumer 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 CO 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 consumer needs a refund outside of the automatic run cycle (for example, an amount paid in error), contact the Service Desk.
Consumers Ineligible Due to Lack of Home and Community Based Care Services
A report was developed that lists consumers 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 consumer did not have any charges for home and community based care services. This report is available on View Direct.
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|EPD and the Pay-In System|
The Pay-In System cannot be used for EPD participants. EPD service participants are not in the Pay-In system. If a consumer is working and chooses not to be in or is not eligible for EPD, they may have a pay-in. If they are not in EPD, they must be in the Pay-In system. EPD participants will pay a Participant Fee (see 461-160-0800) but will not have a pay-in, even if they are receiving in-home services or are participating in the ICP. For more information about the EPD program, refer to OPEN "EPD" Chapter 2, Section 9.
When a consumer is eligible for the EPD Program with services, ONE automatically enrolls the consumer in to the EPD Program and the participant fee will be based on the participant fee calculation or the consumer pay-in calculation, whichever is less. If the consumer does not wish to particpate in the EPD Program, they must contact their CM.
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|State Plan Personal Care (SPPC) and the Pay-In|
Since SPPC is not a waivered program, there is no pay-in for SPPC services. Most SPPC consumers are SSI eligible and qualify for OSIPM. Those that are OHP Plus eligible will often have income over the SSI standard with income up to 185% of the federal poverty level. However, even those consumers with income over the SSI standard will not have a pay-in, since SPPC is not a waivered service. Any SPPC case set up on the pay-in system is an error and will also result in unnecessary payments by the consumer and subsequent refund back back to the consumer.
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|System Generated Notices|
There are several different notices that are system generated that will be sent out to consumer's and providers.
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|Frequently Asked Questions|
If you have questions about pay-in policy or procedures, please send an email to APD.MedicaidPolicy@dhsoha.state.or.us. These questions may be posted anonymously on the site if others might benefit.How do I get a copy of the system generated notices that the consumer and HCW were sent?
If there is a 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 consumer has spent their funds?
If the consumer 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?
Can a consumer get a refund?
Can I process a refund?
When can a consumer expect a refund?
Can I request a refund for a consumer earlier than normal processing times for special circumstances?
What if a consumer pays in advance?
What if a consumer passes away and there is unused money in the account?
What if a consumer moves out of their home, into a facility and there is unused money in the account?
How can I tell if a consumer received a refund?
How can I tell if a consumer may be potentially ineligible on the pay-in system?
My consumer 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 on the current month?
If a consumer’s case is closed or they pass away, will the provider still be paid if I close or death out the case?
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|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|
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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 consumer by a provider.
Excess Income - Earned or Unearned income that is over the OSIPM standard.
In-Home Support Services Definitions - 411-030-0020
Liability - Consumers who receive long term care services and have countable income above the Maintenance Standard, may be required to contribute their adjusted income to the cost of their care or service to remain eligible.
Pay-In - This is the term commonly associated with a consumer's in-home services payment. In rule the term liability includes pay-ins.
Service Priority Level (SPL) / Consumers 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 consumers 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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