512. The term 512 refers to all of the following - a payment system, a form, and a contract between the State and a CBC provider. The 512 payment pays only the state's portion of the services. The 512 system is a series of mainframe screens and can be accessed through the SMRF screen <SMRF enter>
Activities of Daily Living (ADL). Eating, dressing, grooming, bathing, hygiene, mobility (ambulation and transfer), elimination (toileting, bowel and bladder management), cognition, behavior. Individuals are assessed for their ability (or inability) to perform these tasks and are assigned a Service Priority Level based on the results.
Actuarially sound. A commercial annuity which pays principal and interest out in equal monthly installments over the actuarial life expectancy of the annuitant. For purposes of this policy, the actuarial life expectancy is established by the life expectancy table in SPD WG E.1. For transactions (including the purchase of an annuity) occurring:
461-145-0020 and 461-145-0022
Adult Foster Care (AFC). A type of community-based care which provides room and board and 24-hour care and services for aged or disabled individuals 18 or older. The care is contracted to be provided in a home with five or fewer clients. See Chapter 411, Division 050 of the Oregon Administrative Rules for more information. Some providers can apply for a Limited Foster Care license, which contract to provide care to one specific individual.
Advanced Premium Tax Credit (APTC). Individuals who purchase private insurance on the exchange (either state or federal), may be eligible for a federally subsidized tax credit to offset the cost of the insurance coverage.
Aid to the Blind (AB). Denotes the OSIPM subprogram for blind individuals (program B3 or _3).
Aged. In the OSIPM program, aged refers to individuals age 65 or older. In the SNAP program, aged means 60 or older; however, the SNAP program uses the term elderly.
Allocating. Assigning income from an ineligible parent to each non-applying child living in the household in order to determine income eligibility for a child or married adult applying for OSIPM.
Annuitized annuity. A contract or an agreement under which one or more persons receive annuities in return for prior set payments made by themselves or another. The annuities are payable yearly or at other regular intervals for a certain or uncertain period (e.g., for years or for life).
Approved account. A segregated account in a financial institution, the purpose of which is to save to use for future disability-related expenses that would increase the individual’s independence and employment potential. Also included in this definition are accounts regulated by the Internal Revenue Code and used for retirement planning, such as IRAs, 401(k)s, TSAs, and KEOGHs. Approved accounts are used in the OSIPM-EPD program and are excluded as long as the requirements are met.
Assisted Living Facility (ALF). An ALF is a type of Community-Based Facility which houses at least 6 aged or disabled adults and which provides 24-hour assistance with activities of daily living, health, and social needs. Residents of ALFs reside in separate, individual living units, which is the primary difference between an ALF and an RCF. See Chapter 411 Division 054 for more information.
Assumed eligible. A client is assumed for certain medical programs because the individual receives or is deemed to receive benefits of another program. For OSIPM and QMB, receipt of or deemed eligibility for SSI makes an individual assumed eligible (don't forget that individuals must also have Medicare Part A to receive QMB).
Assumed eligible newborn (AEN). A child born to a mother who is receiving Medicaid or CHIP is assumed eligible for medical benefits until the end of the month in which the child becomes one year old, as long as the child lives with the mother. The mother does not have to be continuously eligible for benefits in order for the child to receive the benefits.
BEIN. BENDEX/SDX mainframe screen that identifies SSA benefits.
Beneficiary Data Exchange System (BENDEX). Beneficiary Data Exchange system. This is the SSA interface with DHS shown on a series of mainframe screens.
Blind. In the OSIPM program, blind is denoted by impairment of visual acuity when remaining vision in the better eye, after the best correction, is 20/200.
Blind work expenses (BWE). These are costs that can be used as deductions in calculating adjusted income in the EPD program. They are defined by the Social Security Administration (SSA) as expenses that can be used as reductions to earned income as defined in 20 CFR 416.1112(c)(8).
Branch 5503. Also referred to as 5503, this is the Oregon Health Authority's Statewide Processing Center. As of September 2013, all medical cases except OSIPM, QMB, and the refugee medical program (REFM) cases are carried and administered by branch 5503.
Children's Health Insurance Program (CHIP). Provision of the 1997 Balanced Budget Act funded under Title XXI of the Social Security Act (as opposed to Title XIX, which funds Medicaid). that provides health coverage to children under age 19 in families with income too high to qualify for Medicaid but can't afford private coverage. It is now commonly referred to as MAGI-CHIP. Though it isn't a Medicaid-funded program, it offers the OHP Plus package of benefits.
Children's Intensive In-Home Services (CIIS). CIIS are exclusively intended to enable a child with an intellectual or developmental disability and intense behaviors to have a permanent and stable familial relationship.
411-300-0100 to 411-300-0220.
Citizen/Alien-Waived Emergent Medical (CAWEM). Medicaid coverage of emergent medical needs for individuals who are not eligible for MAGI Medicaid or OSIPM solely because they do not meet citizen/alien status requirements. Pregnant CAWEM clients can receive expanded benefits until they deliver.
Client Maintenance System (CMS). This is a mainframe system which stores medical and cash case data. The information provided to CMS:
Code of Federal Regulations (CFR). CFRs are essentially the federal version of Oregon Administrative Rules and regulate how we administer Medicaid programs.
Commercial annuity. A contract or agreement (not related to employment) by which an individual receives annuitized payments on an investment for a lifetime or specified number of years.
461-145-0020 and 461-145-0022
Community-Based Care (CBC). This is the term is most commonly associated with the services provided in a CBF (see below); however, the definition in 461-001-0000 includes in-home services.
Community-Based Facility (CBF). A client is considered living in community-based facility if the client resides at one of the following community-based care settings licensed by the Department:
Community spouse. Someone who is married to home and community-based care or nursing facility client (institutionalized spouse) but is not in a medical institution (i.e hospital) or nursing facility themselves. This means that a community spouse can sometimes also be an institutionalized spouse; for example if a couple are both receiving in-home services, they would both be an institutionalized spouse and a community spouse to each other.
Continuous eligibility. Continuous eligibility applies to non-CAWEM children under the age of 18 who are receiving OSIPM, MAGI, CHIP, or BCCTP. When a child loses eligibility for one of these programs with time remaining in the 12-month eligibility or determination period, the child’s medical assistance continues for the remainder of the 12-month eligibility period.
The continuous eligibility period is based on the most recent program approval date (or most recent date of request in the case of redeterminations). A child losing eligibility less than 12 months after having been approved for benefits qualifies for continuous program benefits for the balance of the 12 month period following that approval.
To be eligible for continuous eligibility in Medicaid, CHIP, or BCCTP programs, a child must meet all of the following requirements:
Continuous eligibility for benefits ends when the child --
461-135-0010 and 410-200-0420
Cost Sharing Reduction (CSR). Individuals who purchase private health insurance on the exchange maybe be eligible to receive coverage to help pay for things like insurance deductibles and out-of-pocket costs.
Cover Oregon. Cover Oregon was Oregon's health insurance marketplace established under the provisions of the Affordable Care Act. It was designed to enable Oregonians and small businesses to purchase health insurance and apply for federal subsidies to help with costs. In April 2014, its board of directors voted to move determination of individual eligibility for ACA-related health care programs to the federal government beginning in 2015. The federal exchange may be accessed at HealthCare.gov.
Deeming. Assigning a portion of income from an ineligible spouse or ineligible parent to an adult or child applying for OSIPM after allocating to ineligible, non-applying children in the home.
DHR. Officially this acronym was replaced by the DHS (Dept. of Human Services) several years ago, but it is currently used as another name for the mainframe.
Disability determination. The process used to establish whether the individual’s disability meets the definitions used by the Social Security Administration (SSA) in determining eligibility for OSIPM and some Developmental Disability (DD) services. The Social Security Administration also requires disability determinations in order to determine eligibility for Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI).
Disability Determination Services (DDS). Employees of DHS who make disability determinations for federal Social Security benefits (SSI/SSDI). DDS is not to be confused with the PMDDT, which makes disability determinations for APD and DD programs.
Disabled. For OSIPM programs, having a physical or mental impairment, or a combination of these impairments, that meets the definition of disability used by the Social Security Administration when determining eligibility for Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) as defined in 20 CFR Part 404.
For SNAP, the definition of disabled is much different. See OAR 461-001-0015.
Disqualifying transfer. This refers to the practice of giving away assets, usually money or property (or selling for less than fair market value) in order to qualify for Medicaid long-term care.
Elderly. In the SNAP program, it means a person age 60 or older. In the OSIPM program, it means a person age 65 or older and is more commonly referred to as aged.
Employment. In the EPD program, employment refers to an ongoing work activity for which a client provides the Department with one of the following:
Employment and Independence Expense (EIE). The cost of any expense that can be reasonably expected to enhance the individual's independence and employment potential. 461-001-0035. These can be used as deductions in calculating adjusted income in the EPD program.
Express Lane Agency (ELA). A public agency identified in the State Medicaid Plan as an agency capable of making determinations regarding eligibility for children in the MAGI and CHIP programs. For example, DHS is a designated ELA and used SNAP data to determine MAGI eligibility in early 2014.
Express Lane Eligibility (ELE).The Department's option to rely on a determination made by an ELA. ELE qualifies a child for medical assistance benefits based on a finding from another public agency.
Food Stamp Management Information System (FSMIS). Computer system used to calculate and issue SNAP benefits, and track SNAP clients from application through benefit issuance.
General Assistance (GA). Cash assistance to low-income individuals with disabilities who do not have dependent children. This program was discontinued in 2005. Even though the program was discontinued, some of the systems coding regarding the GA is still reflected in CMS on _5 cases, which are currently used to designate presumptive OSIPM cases. References to GA will remain in chapter 461 of the OARs until further notice.
General Equivalency Degree (GED). Equivalent to a high school diploma.
HINQ. This is the main screen of the homecare worker voucher system located on the mainframe. It can be accessed by provider or by in-home service client (recipient) by typing HINQ,p,provider# or HINQ,r,prime#
Impairment Related Work Expense (IRWE). Those costs defined by the Social Security Administration (SSA) that can be used as deductions in calculating adjusted income in the EPD program. To be allowed, the item/service must be related to the impairment and necessary to enable the person to perform their job as defined in 20 CFR 416.976.
Income Eligibility and Verification System (IEVS). In Oregon, for the purposes of determining eligibility, IEVS refers to a series of mainframe screens, as well as the Work Number. See transmittal SS-AR-14-014 for more information.
Inmate. A person living in a public institution who is:
Institutionalized spouse. A married individual who is receiving some sort of long-term-care services (i.e. home and community-based or nursing facility care). In some cases, an institutionalized spouse can also be a community spouse (i.e. both are receiving in-home care services or living in an ALF).
Instrumental Activities of Daily Living (IADL). Also called "self-management tasks", IADLs include housekeeping, laundry, shopping, transportation, medication management, and meal preparation. IADLs do not factor into the SPL calculation; however, assistance with IADLs is available under the K Plan and some DD waivers.
Intentional Program Violation (IPV). For SNAP, this means:
Click the OAR link to learn more about IPVs in other Self-Sufficiency programs.
K Plan Services. First, some background about the term "Plan". A State Plan is a contract between a state and the Federal Government describing how that state administers its Medicaid program. The State Plan sets out groups of individuals to be covered, services to be provided, methods for providers to be paid, and other administrative requirements states must meet in order to participate. In the past, State Plan requirements were more restrictive than waivers. Oregon has a State Plan, but most of our "services" were covered under the 1915(c) waiver, which is why they were called waivered services. In the last few years, the Federal Government has added State Plan "Options." Oregon recently decided to look at moving "services" from the waiver to the State Plan.
Note: The formal name for K-Plan services is Home and Community-Based Care (HCBC).
The K State Plan Option, or the "Community First Choice Option" is a new State Plan option that lets states provide home and community-based care under a State Plan with a 6% increase in Federal matching funds for home and community-based services.
In July 2013, Oregon received approval for an amendment to its 1915(c) waiver and State Plan K Option application which moved all direct services to the K Plan. These include:
Other supplemental services not previously covered under the 1915(c) waiver were added, including:
Prior to July 1, 2013, clients had be eligible for OSIPM to receive home and community-based services. The K State Plan, on the other hand, only requires an individual to have OHP Plus, which includes the MAGI Medicaid programs (excluding CHIP). Because MAGI recipients' Medicaid eligibility is not contingent on having a higher income limit only available under the waiver, they do not have to receive a waivered case management service each month in order to maintain eligibility for services.
Note: Individuals still have to meet the SPL requirements to receive K Plan Services.
Landlord/tenant relationship. For all programs except SNAP, a landlord/tenant relationship exists when:
Legally married. A marriage uniting two individuals according to the provisions of either:
Less Diverted to Spouse (LDS). This is the amount of a service client's countable income he/she can give or "divert" to his/her community spouse. The LDS is calculated by taking into consideration the service client's income, the community spouse's income, shelter expenses, and allowable medical deductions. LDS is a deduction from the service client's countable income and generally reduces the service payment (liability or pay-in). When the community spouse resides separately from the service client (e.g. the client resides in an ALF and the community spouse resides at home), the LDS amount is considered countable income to the community spouse.
Liability. This term is often used in a couple of different ways. In rule, the term liability is a general term that refers to a service client's service payment, regardless of the care setting. In practice, liability is often associated with the CBC or nursing facility service payment and the term pay-in is used to denote the in-home service payment.
Long-term care (LTC). This term can be confusing, because it is sometimes used as the umbrella term encompassing K Plan, DD, nursing facility, and waivered services, or "a broad range of social and health services to eligible adults who are aged, blind, or have disabilities for extended periods of time" including "nursing homes and state hospitals" (see OAR 461-001-0000). Other times, it specifically refers to nursing facility services (see OAR 461-001-0030). It is important to read the rule carefully in which this term appears in order to determine its meaning.
Low Income Subsidy Program (LIS). A federal assistance program for Medicare clients who are eligible for extra help meeting their Medicare Part D prescription drug costs. LIS helps Medicare clients pay their monthly premium, deductible, and co-insurance costs under Part D. LIS is a means-tested program. All clients must qualify on the basis of household income, resources, and size as defined by the Social Security Administration.
Mainframe. Also referred to as DHR or Hummingbird, it is the computer system used by DHS since the late 1970s which, among other things:
Medicaid Management Information System (MMIS). MMIS is a computer system which:
Mental health residential treatment facility. One of the following:
Modified Adjusted Gross Income (MAGI) Medicaid. MAGI Medicaid is a state and federally-funded program which helps low-income Oregonians with medical coverage. One of the goals of the Affordable Care Act (ACA) was to make administration of Medicaid easier while expanding Medicaid coverage to a broader population. In an attempt to make the administration of Medicaid simpler, the ACA calls for the use of information reported on Federal tax filing forms. Adjusted Gross Income is a line item on Federal tax filing forms. This figure is used, with some modifications, in the MAGI determination; hence the program became known as MAGI Medicaid, or MAGI.
MAGI is different from traditional Medicaid programs in that it:
Individuals who are 65 or older can be MAGI eligible under the Parent or Other Caretaker Relative program. Clients who are Medicare eligible can be MAGI eligible under the Parent or Other Caretaker Relative Program or the Pregnant Woman program (some children with Medicare can also be eligible for MAGI). Clients who receive or are eligible to receive SSI or who are receiving other Medicaid coverage are not eligible for MAGI Medicaid programs. The Oregon Health Authority has exclusive authority to administer MAGI programs.
MAGI Adult. This sub-program serves adults age 19-65 who are not pregnant, not enrolled in Medicare, not receiving SSI, and are not parents or caretaker relatives of a minor child. This program replaced the OHP-OPU program with two significant differences: (1) MAGI Adult eligible clients receive the OHP Plus benefit, and (2) there is no longer a reservation list or an enrollment cap.
MAGI Child. This sub-program is available to children under age 19 and replaced the OPP, OP6 and OPC programs.
MAGI CHIP. This sub-program is available to children under age 19 who do not meet the financial eligibility requirement of the MAGI Child program. This program replaced the OHP-CHP program. Note: MAGI CHIP is not a Medicaid program, rather it is funded under Title XXI of the Social Security Act; however, it does offer the OHP Plus package of benefits. This means that CHIP kids can receive SPPC services.
MAGI Parent or Other Caretaker Relative. This sub-program serves individuals of any age who have a dependent child in the home. This program replaced the MAA and MAF programs.
MAGI Pregnant Woman. This sub-program serves pregnant women of any age and replaced the OHP-OPP program.
back to top
NED. This is a SNAP term which applies to households in which all members have No earnings and are either Elderly or Disabled. Households designated as NED are not required to complete a report in the sixth month of the SNAP certification. In addition, NED households in some areas of the state may be certified for 24 months.
Non-Standard Living Arrangement. An individual who is receiving long-term care services (nursing facility and home and community-based care) resides in a non-standard living arrangement. This does not include those receiving State Plan Personal Care Services.
Oregon Health Authority (OHA). The Oregon Health Authority is a state government agency which oversees most health-related programs for the State of Oregon.
Oregon Health Plan (OHP). The Oregon Health Plan Program is a state program that provides health care coverage to low-income Oregonians. OHP is what Oregon calls its Medicaid program. In the past, OHP used alone usually referred to the OHP Standard package of benefits (OHP-OPU), which is now obsolete.
Oregon Health Plan Plus (OHP Plus). OHP Plus refers to the comprehensive package of medical, dental, mental health, and chemical dependency services. While OHP is the general term for Oregon Medicaid, OHP Plus is the specific package of benefits.
Oregon Supplemental Income Program (OSIP). Cash supplements and special need payments to individuals who are aged, blind, or disabled.
Oregon Supplemental Income Program Medical (OSIPM). A Medicaid program which provides medical coverage (OHP Plus) for individuals who aged, blind, or disabled. APD administers OSIPM, while the Oregon Health Authority administers all MAGI programs.
Participant Fee. This is monthly payment, calculated on a sliding scale, that an EPD client must pay in order to remain eligible. The participant fee ranges from $0 to a maximum of $150.00.
Pay-in. This is the term commonly associated with a client's in-home services payment. In rule, the term liability includes pay-ins.
Past Relevant Work (PRW). Work done within the past 15 years, that was substantial gainful activity, and that lasted long enough for the worker to learn to how do it. This information is used by the PMDDT and DDS in the disability determination process.
Program Operations Manual System (POMS). This is the SSA's version of the APD or SS Worker Guides. The POMS provide instructions on how to apply the Codes of Federal Regulations (CFRs) in determining eligibility for SSI, SSB, and Medicare (among other things).
Presumptive Medicaid. Presumptive OSIPM. The term "presumptive" is used because eligible individuals are presumed to meet the SSA's definition of disability.
Presumptive Medicaid Disability Determination Team (PMDDT). The PMDDT is a team of DHS employees who make disability determinations for APD and DD in order for individuals to meet the basis of need for OSIPM prior to SSA making a determination. The PMDDT applies SSA's rules for determining disability.
Private major medical health insurance For purposes of 410-200-0015, this term refers to a comprehensive major medical insurance plan that at a minimum provides physician services; hospitalization; outpatient lab, x-ray, immunizations and prescription drug coverage. This term does not include coverage under the Kaiser Child Health Program or Kaiser Transition Program but does include policies that are purchased privately or are employer-sponsored.
Qualified Individual 1 (QI-1). Refers to the QMB-SMF program (see below). This is the federal terminology for the program.
Qualified Medicare Beneficiaries (QMB). Programs providing payment of Medicare premiums and one program also providing additional medical coverage for Medicare recipients. Each of these programs also is considered to be a Medicare Savings Program (MSP). When used alone in a rule, QMB refers to all MSP. The following codes are used for QMB subprograms:
See the QMB program manual
Residential Care Facility (RCF). An RCF is a type of Community-Based Facility which houses at least 6 aged or disabled adults and which provides 24-hour assistance with activities of daily living, health, and social needs. These are similar to Assisted Living Facilities (ALFs), except resident of RCFs can either reside in separate, individual living units or shared units. In general, RCF residents tend to require more care than those in an ALF. This is likely due to the fact that ALFs must provide individual living units; thus residents must be somewhat independent
Senior Farm Direct Nutrition Program (SFDNP). Food vouchers for low income seniors. Funded by a grant from the US Department of Agriculture.
Service Priority Level (SPL). This is a system of measuring an individual's care needs based on their ability to complete activities of daily living.
SFMU. This is the first of a series of the mainframe screens in the Pay-in system. The pay-in system is used to add or change a client's in-home service pay-in record. The SFMU screen is labeled the "SDSD Client Pay-In System Main Menu"
SMRF. A mainframe screen used to access the 512 system.
SMUX. A mainframe screen used to access the child support master record.
SNAP cash out (FSCO). Some SSI recipients and the elderly living in Clackamas, Columbia, Multnomah and Washington counties may qualify to get their SNAP in the form of cash issued via checks or by direct deposit into a bank account.
Social Security Administration (SSA). The Federal agency which assigns social security numbers; administers the retirement, survivors, and disability insurance programs known as Social Security (see below); and administers the Supplemental Security Income (SSI) program for the aged, blind, and disabled.
Social Security Benefits (SSB). Individuals who worked and paid taxes into the Social Security system can receive monthly benefits when they retire or become disabled (see SSDI below). Dependent children and spouses can receive benefits based on the individual's reported earnings. Surviving spouses and children can collect benefits when the individual dies. They are often referred to as Title II benefits.
Social Security Disability Income (SSDI). Monthly benefits paid to individuals with either severe impairments that will prevent one from doing "substantial" work for a year or more, or a condition that is expected to result in death. Recipients must have paid enough Social Security taxes while they were working to "earn" a benefit. The Social Security Administration categorizes SSDI as Social Security Benefits because they are based on work history and fall under Title II; however, in DHS and APD, most refer to this specific benefit as SSD or SSDI.
Specialized Living Facility (SLF). A facility which provides identifiable services designed to meet the needs of persons in specific target groups which exist as the result of a problem, condition or dysfunction resulting from a physical disability or a behavioral disorder and require more than basic services of other established programs. These services are directed toward helping residents toward more independent living.
Standard living arrangement. A location that does not qualify as a nonstandard living arrangement. Basically this refers to those not receiving long-term care services of some kind (nursing facility or home and community-based care). State Plan Personal Care does not qualify as long-term care services for purposes of determining whether someone is living in a standard living arrangement.
State Plan Personal Care (SPPC). SPPC services are limited personal care services covered by an individual's OHP Plus plan and are distinct from K Plan or waivered services. Though receiving SPPC requires an assessment, one does not need to meet the Service Priority Level requirements; instead, one must require assistance with certain personal care activities. Note: Receiving SPPC is not considered a non-standard living arrangement.
Substantial Gainful Activity (SGA). The term used by SSA to describe a level of work activity and earnings. In the EPD program, an individual is engaging in SGA if their earnings are at or above the EPD income standard.
Supplemental Nutrition Assistance Program (SNAP). Formerly called Food Stamps, SNAP is a program intended to improve the health and well-being of low-income individuals, elderly, and people with disabilities and other groups of people by providing them with a means to meet their nutritional needs.
Supplemental Income Payment (SIP). Prior to 2010, this was typically a payment or need amount of $1.70. This payment brought an SSI client who had other unearned income less than $20 up to the OSIP payment standard. The payment/need was more for clients that were blind. These payments were eliminated in January 2010; however, CMS still requires a SIP of $0 in the N/R field for anyone with SSI coded on the case.
Supplemental Security Income (SSI). A federal income program administered by the SSA and funded by general tax revenues (not an individual's Social Security taxes). It helps aged, blind, and disabled people who have limited income and resources meet basic needs. It is often referred to as Title XVI.
Temporary Assistance to Needy Families (TANF). Cash assistance for families when children in those families are deprived of parental support because of continued absence, death, incapacity or unemployment. Cash assistance used to be known as ADC.
Timely continuing benefit decision notice. A decision notice that informs the client of the right to continued benefits and is mailed no later than the time requirements in 461-175-0050. This is generally no later than 10 days prior to the effective date of the action (except under special circumstances, such as the need for alternate format). Timely notices are also commonly referred to as "10-day notices".
TPQY. Accessed through BEIN or by typing WQY1,SSN in an empty DHR screen. This screen allows you to request updated information from SSA.
UCMS. CMS Case Update screen.
Voucher. These are timesheets issued to Client Employed Providers (homecare workers). Voucher clerks create vouchers in the DHR HINQ screens and they are mailed to homecare workers.
WAGE. DHR screen which displays the Employment Department wage records.
Waivered services. Prior to July 1, 2013, waivered services referred to all services needed to keep a person out of a nursing facility under the 1915(c) Home and Community Based Waiver. As of July 1, 2013, APD waivered services (also referred to as Title XIX waivered services) refers to direct or indirect case management services.
The 1915(c) waivers allow states to provide long-term care services in home and community-based settings under the Medicaid program rather than providing care in institutions such as nursing facilities. Traditionally, waivers provide states more flexibility than traditional Medicaid by allowing states to offer a larger variety of services, including home and community-based services and case management. Up to June 30, 2013 Oregon DHS used 1915(c) waivers to fund all home and community-based care services.
Many APD clients received Medicaid only because they qualified for the waiver, which allows us to serve individuals whose income is greater than the standard Medicaid eligibility (i.e. 300% SSI). This is often called the "special income category."
A State Plan, on the other hand, is a contract between a state and the Federal Government describing how that state administers its Medicaid program. The state plan sets out groups of individuals to be covered, services to be provided, methods for providers to be paid, and other administrative requirements states must meet in order to participate. In the past, state plan requirements were more restrictive than waivers. In the last few years, the Federal Government has added State Plan "Options." Oregon recently decided to look at moving "services" from the waiver to the State Plan.
The K State Plan Option, or the "Community First Choice Option" is a new state plan option that lets states provide home and community-based services under a state plan with a 6% increase in Federal matching funds.
In July 2013, Oregon received approval for an amendment to its 1915(c) waiver and State Plan K Option application which moved all direct services to the K Plan. These include:
Case management, once an administrative function, is now a waivered service; and as stated above, it is the only waivered service DHS administers as of July 1, 2013. Under the K State Plan provisions, individuals in the "special income category" must receive one waivered service (i.e a direct or indirect case management service) every month to maintain financial eligibility for OSIPM.
Prior to July 1, 2013, clients had be eligible for OSIPM to receive home and community-based services. The K State Plan, on the other hand, only requires an individual to have OHP Plus, which includes the MAGI Medicaid programs (but does not include CHIP). Because MAGI recipients' Medicaid eligibility is not contingent on having a higher income limit available under the waiver, they do not have to receive a waivered case management service each month in order to maintain eligibility for services.
Note: What was once referred to as waivered services is now formally referred to as Home and Community-Based Services (HCBS) (see OAR 461-001-0030) and used interchangeably with K Plan or K Services.
Developmental Disability (DD) waivers, on the other hand, still include a variety of services in addition to case management services. The services themselves are not administered by APD or DHS, but by county DD offices or brokerages; however, APD carries the OSIPM case. There are several types of DD waivers:
Though county offices administer the services themselves, the Office of Developmental Disability Services (ODDS), a branch of DHS and under APD, oversees DD services and handles policy, rules, and licensing.
Note: DD individuals who are 18 or older can also receive K Plan services as long as they already qualify for OHP Plus (either OSIPM or MAGI but not CHIP) and meet the level of care requirements (i.e. SPL 1-13).
Eligibility is the decision as to whether a person qualifies, under financial and nonfinancial requirements, to receive program benefits. This decision must be made before budgeting is done.
Budgeting is the process of calculating the benefit level after eligibility has been determined.
The initial month of eligibility is one of the following:
The ongoing month is one of the following:
The payment month is the calendar month for which benefits are issued.
The budget month is the calendar month from which nonfinancial and financial information is used to determine eligibility and benefit level for the payment month.