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Staff Tools | OSIP Program Manual | H. Special Needs
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DHS home | SPD
Staff Tools | OSIP Program Manual | H. Special Needs
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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.
The Department will authorize one-time payments for allowable expenses necessary for clients to set up housing in Oregon in their own homes or apartment, or an assisted living facility as long as the facility is not required to provide the item covered by the payment by contract or by the administrative rule governing assisted living facilities (411-054-0000 to 411-054-0300). Payments are allowed only for the following clients who are returning to the community if they meet the criteria for one of the service priority levels served by the Department according to 411-015-0015(1):
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 rent for housing or temporary housing, ongoing utility costs, medical supplies such as lift chairs, reachers, grabbers, wheelchairs, and transfer trays, or recreational items such as a television or cable television access.
Payment will be authorized only for the minimum amount necessary to establish the client’s basic living arrangement.
OSIP(M) clients who receive SSI, have adjusted income less than the OSIPM program standard,or receive waivered services, a food allowance is allowed for guide dogs and special assistance animals that are individually trained to:
The maximum amount to be authorized for this special need is $50 per month.
Authorization of this special need must be based on a proven medical need to sustain the client's independence.
The Department will authorize—consistent with the restrictions in this rule—a one-time special-needs payment for a home adaptation required by the client’s care plan, if the adaptation is needed to accommodate the client’s physical condition and prevent the client’s placement in a nursing facility.
For a home adaptation:
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.
Providers of the adaptations must ensure that the work being completed meets current building codes.
Adaptations authorized by this rule include only changes to the structure of the building, such as installation of ramps, grab-bars, and railings; widening of doorways; modification of bathroom facilities; and installation of electric and plumbing systems necessary to accommodate the client’s medical equipment or supplies.
OSIP(M) clients who receive SSI, have adjusted income less than the OSIPM program standard, or receive waivered services 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 laundry.
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.
Providers of the repairs or new installations must ensure that the work being completed meets current building codes.
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.
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 first payment that was made for the most recent month.
Clients who are homeowners or buyers are allowed a special need of one year of delinquent real property taxes, penalties and interest, if needed to prevent imminent foreclosure.
Clients who 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 have failed to pay their property taxes, will not receive a property tax special need payment unless the 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.
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:
For an individual not covered by a home and community based care waiver, the special need is the amount of the service payment authorized by the Department and is added to the OSIP maintenance standard to determine eligibility.
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.
To receive the restaurant meals special need OSIP(M) clients who receive SSI, have adjusted income less than the OSIPM program standard,or receive waivered services must have proven medical and nutritional needs that cannot be met with meals purchased with SNAP program benefits.
Clients living in their own homes who are unable to prepare their own meals, but are eligible for SNAP program benefits, may have their meals prepared by attendants that volunteer or are compensated by the In-Home Services program. Clients may also receive, if eligible (per 411-040-0000), Meals on Wheels services to supplement their diet.
The payment standard for restaurant meals is $60 per month.
A client living in 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, in-home waivered services. An OSIP(M) client who receives SSI (except those in a nursing facility), has adjusted income less than the OSIPM program standard, or is eligible to receive or is receiving in-home waivered services is allowed an accommodation allowance if the client meets the criteria as a temporary absence or an additional cost for accommodation. A client aged 18 or older may be eligible for the allowance.
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 insurance, plus the limited standard utility allowance for the FS program provided in 461-160-0420.
Note: Update the LUA amount annually during the financial redetermination.
Additional cost for accommodation. An OSIP(M) client who receives SSI(except those in a nursing facility), has adjusted income less than the OSIPM program standard, or receives in-home waivered services may receive an accommodation allowance if the client's shelter cost exceeds the shelter standard in 461-155-0250(2) and the requirements of one of the following subsections are met:
The accommodation allowance is determined as follows:
Note: Update the LUA amount annually during the financial redetermination.
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.
Clients are not eligible for a special diet allowance if they are receiving any of the following:
OSIP(M) clients who receive SSI, have adjusted income less than the OSIPM program standard, or receive in-home services are eligible for a special diet allowance if they meet the following requirements:
They would be in an imminent life-threatening situation without the diet as verified by medical documentation from a Department-approved medical authority (see 461-125-0830); and
A nutritionist verifies that the special diet needed exceeds the cost of a regular diet.
The amount of a special diet allowance is the lesser of the following:
Local management staff must approve the request for a special diet allowance.
Each special diet allowance must be reviewed at six-month intervals.
Grant a telephone allowance for OSIP(M) clients who receive SSI, have adjusted income less than the OSIPM program standard and for clients receiving in-home services if they are unable to leave their residence without assistance due to a documented medical condition. A client aged 18 or older may be eligible for the allowance.
Allow costs as follows:
SSI-eligible clients or clients with adjusted income less than the OSIPM program standard granted a telephone allowance must apply for a payment through the Oregon Telephone Assistance Program (OTAP). The Department may provide a maximum supplemental payment of $30 for necessary installation charges.
OTAP form: AFS
7254
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. 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.
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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.
The Department may authorize one-time payments for expenses that the Department has determined are necessary to divert or transition individuals from nursing facility services. Payments are allowed for clients who are receiving or eligible to receive community based care.
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.
Payment is not allowed if the item or service may be provided under any other special needs rule in this section.
Payments must be approved in advance by Seniors and People with Disabilities Division central office staff.
Examples:
The payments must be authorized in advance by central office. Contact Sandy Hata at (503) 945-5659 or sandy.k.hata@state.or.us for the necessary authorization.
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.
For a client who is receiving SSI income:
| Payments authorized under this rule are suspended effective August 1, 2011; current payments end on July 31, 2011; and no payments will be authorized after July 31, 2011. |
The following individuals may be eligible for a transportation services payment:
These services are for transportation to non-medical and non-waivered activities and resources approved by the Department. Examples of such transportation services include, but are not limited to: reimbursement for non-commercial transportation not available through natural supports; transportation provided by common carriers, taxicab, or bus; and assistance with purchase of a pass for public transportation.
Reimbursement for non-commercial transportation may be made to family members if they would not or do not already provide the transportation service as a natural support. Reimbursement is limited to mileage only at the full United States General Services Administration mileage reimbursement rate (the same rate that state employees receive). The rate is currently $.51 per mile.
The following items are not eligible for payment under this rule:
Payment for services authorized by this rule may not exceed $50 per month.
Service costs must be verified annually or when questionable. For non-commercial transportation a client verifies this need either orally or in writing by providing the name and location of the activity, the frequency, and total mileage per trip.
Clients can use their transportation service for any activity (shopping, recreation, etc.) as long as it is not covered by another source.
| Payments authorized under this rule are suspended effective August 1, 2011; current payents end on July 3, 2011; and no payments will be authorized after July 31, 2011. |
An individual meeting all of the following requirements is eligible for Emergency Assistance:
Payment for Emergency Assistance:
Authorize payments for Emergency Assistance as follows:
*CMS Need/Resource Entries for EA Payments
Note: The result in this example will be one payment in August for $140 ($130 + $10) and a second payment in September for $10. The total payment received would be $150. Make sure to verify that the correct payment is showing on SCMS.
Note: Emergency Assistance does not have to be authorized as per this example. The requirement is that the total of the payments is made over two months. By making two separate OEA entries on CMS (with one of the OEA N/R’s covering two months), the total payment can be issued via one CMS action that allows the client to receive the bulk of the payment in the first month.
Note: If the case will change from a vendor pay program code (A1, B3, D4) to a cash pay program code (1, 3, 4) to make theses payments it will be necessary to change the case back to a vendor pay program code after the second payment is issued. If the case is not changed back to vendor pay it will go NA. A tickler should be set for the beginning of the month that the second payment will be issued as a reminder to change the case back to a vendor pay program code. Using a compute action, the case should be changed back to a vendor pay program code effective the first day of the following month (i.e. the month after the second payment is issued).
Verification of unexpected costs, loss of income, or loss of resources is required (acceptable verification of costs includes a cost estimate for items/services not yet purchased or a receipt if already purchased). Accept client’s statement with respect to the lack of funds necessary to meet basic needs.
| Payments authorized under this rule are suspended from 08/01/2011 through 11/30/2011. Payments are reauthorized effective 12/01/2011. The authorized payment amount effective 12/01/2011 is $10 per month for eligible clients. |
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 $10 per month (all eligible clients will receive this amount).
Payments are considered a reimbursement of assistance needs, so do not impact SNAP benefits.
If a client 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 clients, authorize the payment with an ISS need/resource code, continuous, in the amount of $10. 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 client begins receiving the services outlined above.
