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OSIP Program Manual

H. Special Needs

Effective 10/1/20

1. Overview

Special needs are needs not included in the basic standard. They may be one-time needs or ongoing needs.

Ongoing special needs are needs that last several months at a consistent cost. Examples are special diets and accommodation allowances. 461-155-0010 is used to determine how special needs are considered for each program.

To be eligible for a special need item, clients must have no other available resources in the community or in their natural support system to meet the need.

To be eligible for a special need item, clients must not be eligible for the item through Medicare, Medicaid or any other medical coverage.

Clients may be eligible for an ongoing special need item if providing the ongoing special need item is authorized in lieu of additional provider service hours pursuant to 411-030-0002 through 411-030-0090 and is more cost-effective.

The Department will authorize payment for one-time and ongoing special needs for the following, in accordance with the policies in this section:

Special needs are items that are not included in the basic standard for each program. They may be one-time needs or ongoing needs.

461-155-0500

2. Community Transition Services

Effective immediately use the K State Plan for community transition services that are authorized under OAR 461-155-0526 (Special Need; Community Transition Services; OSIP and OSIPM), if they can also be authorized under OAR 411-035-0070/0075/0080.  Some services necessary for an individual to transition out of an institutional setting may not be covered under the K Plan, this is the appropriate time to use funds covered under this rule. for example, under OAR 461-155-0526, an individual can qualify for items not covered by the K Plan, such as ID replacement.  For this reason pay reason code 49 is still available, but should only be used when the service cannot be covered under the K State Plan.

When an individual who has been admitted as an inpatient is leaving a psychiatric hospital or is being transitioned out of a nursing facility:

Examples of allowable expenses are expenses for moving belongings; housing security deposits; essential furnishings; eating utensils; food preparation items; deposits for utility hook-ups for heat, electricity and telephone; climate control; and health and safety measures such as pest eradication or allergen control.

Allowable expenses do not include ongoing housing or utility payments and recreational items such as television, cable, or internet access.

Payment will be authorized only for the minimum amount necessary to establish the client’s basic living arrangement.

461-155-0526

3. Food for Guide Dogs and Special Assistance Animals

OSIP(M) clients who receive SSI, have adjusted income less than the OSIPM program standard, or receive home and community based care, a food allowance is allowed for guide dogs and special assistance animals that are individually trained to:

The allowance should be the actual monthly cost of food, with a maximum amount of $50 per month.

Authorization of this special need must be based on a proven medical need to sustain the client's independence.

461-155-0530

4. Laundry Allowances

OSIP(M) clients who receive SSI, have adjusted income less than the OSIPM program standard, or receive home and community based care are eligible for a laundry allowance if they have proven, excessive, coin-operated laundry facility costs and do not:

This allowance may not exceed an amount required to wash and dry the client's laundry.

461-155-0580

5. Home Repairs

To be eligible for a Home Repair the individual must be eligible to receive in-home services under OAR chapter 411 division 030.

The Department will authorize a special-need payment for home repairs for homeowners or buyers as a one-time special need within the following limits:

The repairs must be needed to remove a physical hazard to the health and safety of the client.

Payment for repairs authorized by this rule:

The repairs must cost less than moving to another home.

Payment is limited to the lowest possible cost that will provide adequate facilities. The client must provide three competitive bids for the repairs, unless there are not three providers of the service in the local area.

Before approving payment for repairs or new installations, the Department will consider the use value and will determine whether it is consistent with the care plan for the client to remain in the house.

Contractors who complete the repairs or new installations must ensure that the work being completed meets current building codes. Payment is only made for home repairs performed by a licensed and bonded construction contractor.

Repairs or replacements include, but are not limited to:

Clients with life estates are not eligible for this special need allowance. The person who will benefit from the life estate, following the death of the client, is considered responsible for the home repairs.

461-155-0600

6. Moving Costs

The Department will authorize payment for the cost of moving a client’s household effects as a one-time special need if:

Payment for moving costs authorized by this rule:

Payments necessary for a one-time move may be made over a period not to exceed 30 consecutive days.

A filing group that has received a payment for moving costs under this rule is not eligible for a moving cost payment again until the first day of the twelfth month following the receipt by the filing group of the most recent payment for moving costs.

461-155-0610

7. Property Taxes

Clients who are homeowners or buyers are allowed a special need in an amount equal to the cost of one year of delinquent real property taxes, penalties and interest, if needed to prevent imminent foreclosure.

Clients whose property taxes have not been paid and are eligible for the Oregon Property Tax Deferral Program must opt to defer property taxes. If necessary, the state may provide payment for back property taxes, to bring the tax current, to allow clients to defer their ongoing property taxes.

Clients who have not chosen to defer their property taxes, and whose property taxes have not been paid, will not receive a property tax special need payment unless an exception is authorized by the Department's Estates Administration Unit. The exception will be based on the value of the property, the potential of foreclosure and the potential of an Estates Administration Unit recovery of such property.

Imminent foreclosure is indicated by a formal notice of foreclosure.

461-155-0620

8. Community-Based Care

Notwithstanding the definition at 461-001-0000, for purposes of this section, a client is considered living in community based care if the client resides at one of the following care settings licensed by the Department:

If a client who meets the applicable income requirements begins living in a community based facility:

Spouses who each receive SSI and receive services in a community based care facility, are eligible for a payment in the amount that equals the difference between the OSIPM standard for a one-person need group and the individual's total countable income. If one spouse has income above the OSIPM standard, the excess income is applied to the other spouse's countable income.

461-155-0630

9. Restaurant Meals THIS RULE IS REPEALED

 

10. Accommodation Allowance

An OSIPM client who is 18 or older and either receives SSI, has adjusted income less than the OSIPM income standard, or is eligible to receive or receiving in-home services is potentially eligible for an accommodation allowance if the client:

A client whose primary residence is a nursing facility is not eligible for an accommodation allowance. A client living in a nonstandard living arrangement is not eligible for an accommodation allowance unless they are receiving, or are eligible to receive after a temporary absence, home and community based care (see OAR 461-001-0030) in-home services. Note: This is one of the factors that distinguish this special need from the deduction to maintain a home authorized under OAR 461-160-0630. See OSIPM E.4 for more information on this deduction.

Temporary absence of client from home. A temporary accommodation allowance may be authorized, where permitted above, if a client meets the following criteria:

The allowance may be authorized for six months. If the client continues to meet the criteria after six months, an extension may be approved in writing by a supervisor.

The accommodation allowance equals the total of the client's housing cost, including taxes and homeowners insurance, plus the limited standard utility allowance for the SNAP program provided in 461-160-0420.

Note:  Update the LUA amount annually during the financial redetermination.

Example 1:  Temporary absence
Pat is an OSIPM client whose monthly income is $935.00 per month in SSB.  Pat rents an apartment for $600.00 per month.  In addition, Pat pays for all of the utility costs.  A homecare worker provides Pat with 50 hours of care per month.  Pat has a stroke on April 29th, and spends four days in the hospital followed by a nursing home admission for physical therapy and occupational therapy.  Pat’s doctor expects that Pat can go home after meeting certain therapeutic benchmarks, and opines that these benchmarks will be met within 60 – 90 days of admission to the nursing home.  When the benchmarks are met, Pat will be physically able to return to the apartment and resume receiving care from the homecare worker.

  $600.00 Rent + $341.00 Limited Standard Utility Allowance = $941 accommodation allowance payment 

Additional cost accommodation based on increased rent due to a disability. An additional cost accommodation may be authorized, where permitted above, if:

The accommodation allowance is determined as follows:

For a client who receives an accommodation allowance based on increased costs associated with access by a person with a disability, the amount of the accommodation allowance is limited to the amount of the increase in housing cost associated with the individual’s access needs.

Example 2:  Disability accommodation
Sasha is an OSIPM client who receives SSI.  Sasha is paralyzed from the waist down, but lives alone in a ground-floor one-bedroom apartment with a wheelchair accessible shower, widened doorways, and lowered counter tops.  This apartment’s accommodations allow Sasha to live independently. Sasha’s apartment is one of four such accessible units in the apartment complex.  The four accessible units rent for $600.00 per month.  Sasha has provided a copy of a letter from the property management company stating that the other standard units in the apartment complex rent for $475.00 per month. 

$600.00 rent for accessible apartment - $475.00 rent for a standard apartment = $125.00 accommodation allowance payment

Additional cost accommodation based on need for additional bedroom for service provider. An accommodation allowance based on increased costs associated with the client’s need for a home with an additional bedroom for a service provider may be provided to a client who:

Note:  Update the LUA amount annually during the financial redetermination.

Example 3:  Additional bedroom for homecare worker
Angel is an OSIPM and in-home service recipient whose income totals $1175.00 per month in SSDI.  Angel requires full assistance in mobility, eating, bath/hygiene, elimination, and dressing/grooming and is independent in cognition.  Angel has several family members who are able to provide care during the daytime, but typically requires 12-16 hours per day of service from homecare workers throughout the night.  Particularly, every 3 hours Angel needs to be repositioned and to have an undergarment change.  Each occurrence takes approximately 15 minutes.  Because a homecare worker needs to be available throughout each night, and because Angel’s service needs can be scheduled, many of Angel’s homecare workers work overnight.  Angel has a 2-bedroom apartment, so the overnight homecare workers can sleep there.  Angel’s rent is subsidized through Section 8, and the unsubsidized rent is $1,200.00 per month.  Angel’s actual subsidized monthly rent payment amount is $342.60.

Special requirements. A client who rents and qualifies for an additional cost allowance, must take the steps necessary to obtain subsidized housing under any federal or state housing program. A client who fails, at any time, to take the steps necessary to obtain subsidized housing reasonably available is ineligible for the allowance. A client, who has been denied or revoked from participation in any rent subsidy program based on the client's own actions is ineligible for benefits under this rule.

A client who rents housing and refuses subsidized housing will no longer be eligible for an accommodation allowance, except that if the housing that is offered is not suitable, related to accommodations, and the client continues to have increased costs related to accommodations in the client's current living situation, the accommodation allowance may continue until such time as appropriate subsidized housing is found.

461-155-0660

11. Special Diet Allowance

Clients are not eligible for a special diet allowance if they are receiving any of the following:

In OSIP(M), an individual receiving SSI, having adjusted income less than the OSIPM standard under OAR 461-155-0250, or receiving in-home services under OAR chapter 411 division 030 is eligible for a special diet allowance if all of the following requirements ar met:

For clients who have difficulties understanding what documentation is needed, staff may include the information found in the three primary bullet points above as part of the pending notice.

The amount of a special diet allowance is calculated as follows:

Example:
The client provides the necessary documentation from a Department approved medical authority and from a licensed dietitian showing that they need an increased amount of high-quality protein, in this case the dietitian states they need 8oz of lean chicken breast a day and can no longer receive their protein from 6oz of ground beef a day, which they are currently purchasing for $25 a month, verified by receipt. The client provides a recent receipt from their local grocer showing chicken breast is $4/lb and the client states they will need $60.20 a month for the chicken breast. Because the client will no longer be spending $25 a month on ground beef, the worker subtracts this from the amount needed and issues a Special Diet Allowance of $35.20.

$4/lb ÷ 16oz in a pound = $0.25 per oz.
$0.25 per oz. x 8oz a day = $2 a day
$2 x 7days = $14 a week  
$14 x 4.3 = $60.20 a month

$60.20 - $25.00 = $35.20 special diet allowance

Each special diet allowance must be reviewed annually.

461-155-0670

12. Supplemental Communication Allowance

A communication allowance is allowed for the following clients who live in their own home, are 18 years of age or older and are unable to leave their residence without the assistance of another person due to a documented medical condition:

The communication allowance may cover the following, and is limited to a maximum of $25 per client per month:

Eligible clients must apply for or receive a payment through the Oregon Lifeline Program (Formerly the Oregon Telephone Assistance Program, or OTAP). See APD WG D.6 for more information about the Oregon Lifeline Program/OTAP. The Department may provide a maximum supplemental payment of $30 for necessary installation charges.
Each client is eligible for a single communication allowance valid for either telephone service or broadband service.

461-155-0680

13. Personal Incidentals and/or Room and Board Allowances

Personal incidentals and room and board allowances are allowed for the following clients to avoid placement in a nursing facility or leaving a nursing facility or an acute care hospital to reside in a community based care facility (see 461-155-0630(1)). The payment amount is prorated in the first month for clients who move to a community based care facility on any day other than the first day of the month.

Room and board only, without personal incidentals, may be paid for an individual to reside in a community based care facility (see 461-155-0630(1)) to avoid placement in a nursing facility when an individual is leaving a public institution (see 461-135-0950) and the individual’s SSI is suspended, subject to the following provisions. The payment amount is prorated in the first month for an individual who moves to a community based care facility on any day other than the first day of the month.

461-155-0700

14. Diversion Services

The Department may authorize one-time payments for expenses that the Department has determined are necessary to divert individuals who might otherwise be served in nursing facilities to community-based care (CBC). Payments are allowed for clients who meet SPL 1 through 13 under 411-015-0015(1)(a).

Payments will be authorized at the lowest possible cost.

To be eligible for payment, clients may not be eligible for the item through Medicare, Medicaid, or any other medical coverage.

Payment for a household item is not allowed if the community based care facility is required to provide the item by contract or administrative rule. This includes payment for lift chairs if the other requirements for this special need are met.

Payment is not allowed if the item or service may be provided under any other special needs rule in this section.

Effective 7-1-13 these payments no longer must be approved in advance by central office staff.

Examples:

Contact Amy Gordin at (503) 945-5659 or amy.gordin@state.or.us if you have any questions.

Once authorized, issue the payment by DHS 437 using pay reason code 59. You will not be able to generate the DHS 437 from Oregon ACCESS until a drop-down has been added to the system for pay reason 59. The new drop-down will be “NF Diversion & Transition.” Until that can be accomplished, use the DHS 437 from the forms server.

461-155-0710

15. Prescription Drug Co-pay Coverage

For a client who is receiving SSI income:

461-155-0688

 

16. In-home Supplement

The authorized payment amount is $22 per month for eligible individuals.

In the OSIPM program the Department may provide a supplementary payment for a client who meets the  requirements of all of the following subsections:

The amount and duration of payments authorized is subject to availability of funding.  The current authorized payment amount is $22 per month (all eligible individuals will receive this amount).
Payments are considered a reimbursement of assistance needs, so do not impact SNAP benefits.

If an individual chooses to pay their homecare worker for completing any assistance covered by this special need, they need to advise the homecare worker that they are not considered a homecare worker while providing the assistance, they will not be covered by workers' compensation while providing the assistance, and any hours worked while providing the assistance will not count towards eligibility for health insurance or the accrual of paid leave.

For new recipients, authorize the payment with an ISS need/resource code, continuous, in the amount of $22. This must be done during integration as ACCESS has not been updated with the special need. Payments can also be issued via 437 using pay reason 3E. The effective date is the date that the SSI only individual begins receiving the services outlined above.  AMH individuals receiving SPPC may be eligible for this payment, but payment must be issued via 437.


461-155-0575

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