SERVICES

All services purchased with Support Services dollars are what is known as a "social benefit". A social benefit is a service "solely intended to assist an individual with disabilities to function in society on a level comparable to that of an individual...who does not have a disability". The benefit can never:

• Duplicate services and benefits otherwise available to citizens, regardless of disability (such as paying for a college class since people with or without disabilities must pay college tuition.)
• Provide financial assistance with food, shelter or clothing
• Replace any other service that is available elsewhere in the community (also known as "natural supports") like Vocational Rehabilitation or services from a school district
• Exceed the amount in the authorized Individual Support Plan.
  

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NON-ALLOWABLE CHORE SERVICES EXPENSES:

• Ongoing home maintenance and housekeeping services.
• Lawn and yard maintenance.
• Routine expenses associated with moving residence, e.g. moving furniture and belongings, cleaning apartment to obtain cleaning deposit.
• Remodeling or new construction in and around the home.
• Pet washing and grooming.
• Washing vehicles.
• Normal household cleaning supplies.

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COMMUNITY INCLUSION SUPPORTS
Provide support for individuals to participate in activities in integrated settings to facilitate independence and promote community inclusion and contribution.

Skill instruction and/or attendant care support to participate in typical adult activities which allows the individual to acquire, retain or improve skills that enhance independence,
productivity/employment integration and/or maintain the individual’s physical and mental skills.

Attendant care to participate in typical adult activities such as recreational activities, exercise programs. Portion of payment for camp that purchases specific support for an individual provided by a qualified provider.

Mobility training and instruction in use of local transportation services.

Sheltered workshop services where goals for productivity and contribution are clearly identified.

NON-ALLOWABLE EXPENDITURES FOR COMMUNITY INCLUSION SUPPORTS:

• Costs for transportation, food, shelter, and entertainment that would normally be incurred by anyone on vacation, regardless of disability, and are not strictly required by the individual’s need for personal assistance in all home and community settings.
• Portion of camp fees not directly associated with specialized supports for the individual, e.g. room, board, administration.
• Expenses that would normally be paid by adults without disabilities in pursuit of strictly recreational or personal interests, e.g. video rental, tickets for movies and concerts, internet fees, “1-900” phone calls, admissions to sporting events, health club dues, horseback riding fees, conference fees.
• Drivers education classes or 1:1 skill training around driver training.
• GED classes.
• Parenting classes.

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COMMUNITY LIVING SUPPORTS
Services provided for the purpose of facilitating independence and promoting community integration by supporting the individual to gain or maintain skills to live as independently as possible in the type of community-based housing the individual chooses.
Supports include developing or maintaining skills in self-care and self-management, directing supports, caring for immediate environment.

Examples of service are:

• Personal skills: eating, bathing, dressing, personal hygiene, mobility.
• Socialization: development or maintenance of self-awareness and self control, social responsiveness, social amenities and interpersonal skills.
• Communication: development or maintenance of expressive and receptive skills in verbal and non-verbal language, functional application of acquired reading and writing skills,
• Personal Environment: development or maintenance of skills such as planning and preparing meals, budgeting, laundry and housecleaning.

NON-ALLOWABLE COMMUNITY LIVING SUPPORTS SERVICES:
Services delivered within the home to individuals who pay privately for services in licensed or certified facilities.

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ENVIRONMENTAL ACCESSIBILITY ADAPTATIONS
Physical adaptations which are necessary to ensure the health, welfare, and safety of the individual in the home, or which enable the individual to function with greater independence in the home.

• Environmental modification consultation to determine the appropriate type of adaptation;
• Installation of shatter-proof windows;
• Hardening of walls or doors; specialized, hardened, waterproof or padded flooring;
• An alarm system for doors or windows;
• Protective covering for smoke detectors, light fixtures, and appliances;
• Sound and visual monitoring systems;
  Fencing;
• Installation of ramps and grab-bars;
• Installation of electric door openers;
• Adaptation of kitchen cabinets/sinks;
• Widening of doorways, handrails, modification of bathroom facilities;
• Individual room air conditioners for individuals whose temperature sensitivity issues create behaviors or medical conditions that put themselves or others at risk;
• Installation of non-skid surfaces, overhead track systems to assist with lifting or transferring;
• Specialized electric and plumbing systems which are necessary to accommodate the medical equipment and supplies which are necessary for the welfare of the individual;
• Vehicle modifications to meet unique needs (e.g. lift, seats, head and leg rests and belts, special safety harnesses or other modifications to keep the individual safe in the vehicle). Repair of lift.

NON-ALLOWABLE ENVIRONMENTAL ACCESSIBILITY ADAPTATIONS:

• Generic fire safety equipment.
• General household maintenance and repair.
• Adaptations or improvements to the home which are of general utility, and are not of direct medical or remedial benefit to the individual, such as carpeting, roof repair, central air conditioning, etc.
• Adaptations to the home that add to the total square feet of living space of the home.
• Adaptations and modifications not constructed in accordance with applicable State or local building codes.
• Adaptations and improvements not necessary or cost-effective, e.g. covering porch used for equipment storage when tarp will adequately protect the equipment, installing extra under-carpet padding throughout a rental unit when individual can be adequately protected with more portable personal safety devices.
• Materials or equipment that have been determined unsafe for the general public by recognized child and consumer safety agencies.
• Environmental adaptations in more than one location without specific SPD approval.
• Equipment that costs over $500 for which a Promissory Note has not been obtained.
• Modifications over $5000 for which the state’s interest was not properly secured via a lien and/or for which other conditions outlined in OAR 411-340-0150(9)(b)(C-D) are not met.

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FAMILY TRAINING
Training and counseling services for the family of an individual to increase capabilities of the family to care for, support and maintain the individual in the home.

Services are provided by licensed psychologists, professionals licensed to practice medicine, social workers, counselors, or in organized conferences and workshops that are limited to topics related to the individual’s disability, identified support needs, or specialized medical or habilitative support needs.

Instruction about treatment regimens and use of equipment specified in the Individual Support Plan
Information, education and training about the individual’s disability, medical, and behavioral conditions.

Counseling for the family to relieve the stress associated with caring for an individual with disabilities.

NON-ALLOWABLE FAMILY TRAINING EXPENDITURES:

• Pay for family training to carry out educational activities in lieu of school for school-age individuals.
• Fees, travel, lodging, and other expenses for conferences when the training is on topics not directly required to carry out the support plan of the individual with disabilities or when training essential for an individual’s care may be effectively provided through less expensive means such as use of state and local experts, books, videotapes, etc.
• Fees, travel, lodging, and other expenses for family members who are not active care providers.
• Training for paid caregivers.
• Teaching family members sign language.
• Mental Health Counseling, treatment or therapy.
• Parenting classes

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HOMEMAKER SERVICES
Support consisting of general household activities such as meal preparation and routine household care provided by a trained homemaker.

Services can be provided only when the person normally responsible for these activities is temporarily absent OR
unable to manage the home as well as care for self and individual in the home OR needs to devote additional time to care for the individual.

HOMEMAKER SERVICES CANNOT BE USED FOR:

• Lawn and yard maintenance
• Pet washing and grooming
• Washing vehicles
• Activities that are not of direct benefit to the individual with disabilities
• Painting, roofing, other home maintenance and repair tasks
• Heavy one-time cleaning tasks associated with Chore Services
• General household cleaning supplies

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OCCUPATIONAL THERAPY
Services of a professional licensed under ORS 675.240, which are defined under the approved State Medicaid Plan, except that the amount and duration specified in the State Medicaid Plan, may be exceeded.

OHP and private/other insurance should always be used as the first funding source.

The use of Support Service funds to purchase occupational therapy for individuals not on Medicaid is limited to those services covered by the State Medicaid Plan. Only covers services that Oregon Health Plan covers.

Generally, these services are assessment, family/provider training to carry out specific recommendations, consultation, and direct hands-on therapy provided by an appropriately-licensed or -certified professional. Covers services once OHP limits have been reached and there must be written proof that OHP limits have been reached.

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PERSONAL EMERGENCY RESPONSE SYSTEMS

Electronic devices required by certain individuals to secure help in an emergency for safety in the home and the community.

Services are limited to people who live alone or are alone for significant parts of the day and would otherwise require extensive routine supervision OR would otherwise require an attendant when out in the community.

Portable “Help” button. Allowable costs include one time cost of installation and monthly service fee.

Cell phone services under listed circumstances:

• “As a means of securing help in an emergency situation when the individual is outside the home and needs assistance due to accident, injury or inability to find their way home” and
• Not for convenience or general purpose use. Costs associated with non-emergency use are prohibited
  

PHYSICAL THERAPY

Services provided by a professional licensed under ORS 688.020 that are defined under the approved State Medicaid Plan, except the amount and duration specified in the State Medicaid Plan may be exceeded. OHP and other insurance should always be used as the first funding source.

The use of Support Service funds to purchase physical therapy for individuals not on Medicaid is limited to those services covered by the State Medicaid Plan. See DMAP (Division of Medical Assistance Programs) provider guide site or call the OHP provider to determine whether an item is covered.

Only covers services that Oregon Health Plan covers. Generally, these services are assessment, family/provider training to carry out specific recommendations, consultation, and direct hands-on therapy provided by an appropriately-licensed or -certified professional. Covers services once OHP limits have been reached and there must be written proof that OHP limits have been reached.

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RESPITE CARE
Respite is short-term care and supervision provided because of the absence, or need for relief, of persons normally providing the care to individuals unable to care for themselves.

Respite may be provided in:

• the individual’s home,
• a respite provider’s home,
• a foster home, a group home,
• a licensed day care center,
• a community care facility that is not a private residence.
• Temporary respite care, which is provided on less than a 24-hour basis, e.g. staying with a neighbor for the afternoon, bringing a care provider in to the home for a few hours in the evening every few weeks to allow the caregiver to leave the house for recreation.
• 24-Hour overnight care which is provided in segments of 24-hour units that may be sequential, e.g. arranging for the individual to spend the weekend away from home at a care provider’s home or foster home, bringing a care provider to the individual’s home while the primary caregiver goes on vacation for a week

NON-ALLOWABLE RESPITE SERVICES:
Basic meals for individual with disability unless as part of short-term stay in Medicaid-approved facility.

Generic vacation travel and lodging expenses.

Ongoing long-term service, approximately 8 hours/day, five days a week.

Substitute care to allow a caregiver to attend school or work.

Nursing care facilities

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SPECIAL DIET

Specially prepared food and or particular types of food needed to sustain the individual in the family home.
Special diets must be ordered by a physician and monitored by a dietitian periodically.

Special diets are supplements and are not intended to meet an individual’s complete daily nutritional requirements. They do not provide or replace the nutritional equivalent of meals and snacks normally required regardless of disability.
Other uses: High caloric supplements, gluten-free supplements and ketogenic or other metabolic supplements.

NON-ALLOWABLE SPECIAL DIET EXPENDITURES:

• Items such as diet drinks and body-building formulas, purchased for weight loss or gain which could be achieved using generic foods and dietary guidelines.
• Experimental nutritional supplements or regimens, such as combinations of vitamins and minerals purported to cure or alleviate symptoms of Autism, Down Syndrome, or other developmental disabilities and which have not achieved general professional acceptance as essential to management of these conditions.
• Food or equipment that can be purchased through the Oregon Health Plan or private insurance.
• A full nutritional regimen, i.e. the nutritional equivalent of three meals a day with snacks. (Example: Will not purchase all food for an individual who has a physician’s order for gluten-free products while the household food budget is used to provide generic diets to the rest of the household. Will only purchase the supplement ordered by a physician and monitored by the dietitian.)
• Food for the entire household.
• Paying “cost comparison” difference between a typical diet and a special diet.

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SPECIALIZED MEDICAL EQUIPMENT
Devices, aids, controls, supplies, or appliances which enable individuals to increase their abilities to perform activities of daily living or to perceive, control, or communicate with the environment in which they live.
Includes:

• items necessary to support a healthy life,
• ancillary supplies and equipment necessary to the proper functioning of such items,
• durable and non-durable medical equipment not available under the Medicaid State Plan.

Equipment, supplies and services must:

• Be reasonable or necessary for the treatment of the disability.
• Be determined appropriate and be properly prescribed by a licensed practitioner practicing within his or her scope of practice or licensure.
• Not be considered experimental or investigational, deviate from acceptable and customary standards of medical practice or for which there is insufficient outcome data to indicate effectiveness.
  

OHP and private insurance should always be used as the first funding source. If OHP or the private insurance denies funding for the item, Support Service funds can be used if the following criteria is met:

• Purchase of the equipment is cost effective because it will reduce other costs in another area such as the reduction in hours of needed support staff.
• The item is a medical/disability related necessity and is not for convenience.
• The item is the basic item at the minimum cost that meets the individual’s needs.

If the OHP or a private insurance will pay for an item but the maximum allowable rate will not cover the specific type or brand of item desired, Support Service funds cannot be used to make up the difference in cost. Individuals should consult with their health plan staff, such as the Exceptional Needs Care Coordinator, if they have difficulty locating an item for the maximum allowable rate.

The use of Support Service funds to purchase medical equipment and supplies for individuals not on Medicaid must follow the same criteria used for individuals receiving Medicaid.

• Adaptive equipment for eating (i.e. utensils, trays, cups, bowls that are specially designed to assist an individual to feed him/herself).
• Incontinence items or devices
• Manual Wheelchair for mobility when power chair won’t fit in house.
• Specially designed clothes to meet the unique needs of the individual with the disability (e.g. clothes designed to prevent access by the individual to the stoma, etc.)
• Assistive technology items.
• Computer software (used by the individual to express needs, control supports, plan and budget supports). Augmentative Communication devices.
• Environmental adaptations to control lights, heat, stove, etc.
• Sensory Stimulation equipment and supplies that help an individual be calm, provide appropriate activity or safely channel an obsession (e.g. vestibular swing, weighted blanket, tactile supplies like creams and
  lotions).
• Purchases, rentals, repairs covered by OHP for durable medical equipment after OHP limit has been reached.
  

Supplies required to implement communication or behavior programs purchased from providers who do not have Medicaid vendor status when:

1. SPD variance has been obtained;
2. The program is professionally designed to meet specific objectives; and
The program is regularly monitored and adjusted on the basis of progress toward objectives.

NON-ALLOWABLED SPECIALIZED MEDICAL EXPENDITURES:

• Work-related clothing available through a Vocational Rehabilitation employment plan.
• Generic household furnishings, personal clothing (for individual or family), and other purchases made because of financial need.
• Materials or equipment that have been determined unsafe for the general public by recognized consumer safety agencies.
• Items which are needed solely to allow a school-aged individual to participate in school.
• Items not of direct medical or remedial benefit to the individual.
• Equipment that is not necessary or cost-effective.
• Equipment that costs over $500 for which a promissory Note has not been obtained.
• Purchase of equipment OHP covers when individual is not Medicaid eligible.

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SPECIALIZED SUPPORTS
Treatment, training, consultation or other unique services necessary to achieve outcomes in the plan of care that are not available through the State Medicaid Plan services or other Support Services. Typical supports include the services of a behavior consultant, a licensed nurse or a social/sexual consultant to:

1. assess the needs of the individual and family including environmental factors
2. develop a plan of support
3. train caregivers to implement the support plan
4. monitor implementation of the plan
5. revise the plan as needed

When behavioral and emotional issues are related to an individual’s developmental disability, provide training and consultation in areas of:

• Self control
• Self calming
• Behavior change
• Anger management
• Relationships
• Sensory stimulation
• Social responsiveness
  

Behavior Consultation consists of:

• Assessment of the needs of the individual and the family and the environmental factors that affect the behavior;
• Development of a positive behavior support plan;
• Training and implementation of a positive behavior support plan with the family and providers;
• Revision and monitoring of the plan as needed to prevent injury to the individual or others.

Social sexual consultation consists of:

• Assessment of the individual and the environmental factors that effect the behavior;
• Development of a support plan with the individual, family and providers;
• Implementation, training, monitoring and revision of the plan as needed to meet the identified outcomes of the plan.

Nursing Consultation consists of:

• Assessment of the individual;
  Development of a nursing support plan with the individual, family and providers;
• Implementation, training, monitoring and revision of the plan as needed to meet the identified health outcomes of the plan.

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SPEECH AND LANGUAGE THERAPY
Services of a professional licensed under ORS 681.250 that are defined under the approved State Medicaid Plan, except the amount and duration specified in the State Medicaid Plan may be exceeded. OHP and other insurance should always be used as the first funding source. The use of Support Service funds to purchase speech and language therapy for individuals not on Medicaid is limited to those services covered by the State Medicaid Plan.

Only covers services that Oregon Health Plan covers. Generally, these services are:

• assessment,
• family/provider training to carry out specific recommendations,
• consultation,
• direct hands-on therapy provided by an appropriately licensed or certified professional.

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SUPPORTED EMPLOYMENT
Provision of job training and supervision available to assist an individual who needs intensive ongoing support to choose, get, and keep a job in the community business setting.
Services need to be planned in partnership with public vocational assistance agencies (Oregon Vocational Rehabilitation Services or Oregon Commission for the Blind) and school districts and through Social Security Work Incentives when available.

• Job exploration and coaching.
• Specialized work equipment or clothing not covered by the employer (under ADA).
• Specialized training required for the job and not covered by employer, OVRD, or school.
• Training for co-workers on how to provide individual support on the job.
• Consultation regarding self-employment.
• Payment for co-workers if time is over and above regular job or activities are over and above reasonable accommodation.
• Community assessment.

Must work with school and OVRD/Commission for the Blind and negotiate if/what supports they can cover. If they confirm in writing that they cannot, then Support Service funds can be used.

NON-ALLOWABLE SUPPORTED EMPLOYMENT EXPENDITURES:

• Payment for the supervisory activities rendered as a normal part of the business setting.
• Incentive payments made to an employer to encourage or subsidize the employer’s participation in a supported employment program;
• Payments passed through to users (e.g. as wages or OJT subsidized wages) of supported employment programs.
• Payments for vocational training that is not directly related to an individual’s supported employment program.

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NON-ALLOWABLE TRANSPORTATION EXPENDITURES:

• Purchase of individual or family vehicles.
• Routine vehicle maintenance, repair, insurance, fuel.
• Ambulance services.
• Costs for transporting someone other than the individual with disabilities.
• Payment for costs associated with transporting an individual to a medical appointment.