Oregon Project Independence OPI Module 2 – Forms & Fees

Oregon Project Independence OPI Module 2 – Forms & Fees
Summer 2014 Mark Acuna NWSDS

OPI Module 2 This training provides an overview of OPI forms and fees. We will look at approved forms and discuss their use and how to fill them out.

Concerning OPI Forms: OPI rules state: “The collection of required program and fiscal records and data associated with OPI must be on forms and data systems as approved by the Department.” (1)(a)

The Department of Human Services in collaboration with the O4AD, AAA directors, and SUA have agreed that all AAAs will use specific forms in order to collect consistent information across the state for the OPI Program. APD-AR

Additional forms for the OPI program are required due to collective bargaining agreements made with the state-wide home care worker union or various home care agency contracts. Following is a list of those forms to be used by AAA’s:

Approved forms for OPI include:
SDS 287 J - OPI Risk Tool SDS 287 K - OPI Fee Determination SDS 287 L - OPI Service Agreement SDS Task List SDS 4105 – Homecare worker Notice

Approved forms - continued: SDS 354 - Worker’s Comp Agreement
MCS Notice of Privacy Practices MCS Acknowledgement of Receipt of Privacy Practices SDS 546 N – Service Plan MSC Authorization (release of information)

Let’s begin with the Process
at the Home visit: Complete an OPI CAPS assessment. Complete a 287J OPI Risk assessment. Gather income & medical deduction information ( for use with form 287K ). Discuss possible service options available in your Area Plan.

Let’s begin with the forms used
at the Home visit: OPI Risk Tool 287J The 2090 Notice of Privacy Practices. The 2092 Acknowledgement of Receipt of Privacy Practices. (Optional but helpful) The 2099 Authorization

Let’s Look at the Forms themselves,
and how to use them. Note: You should use the most recent OPI forms found on the DHS Forms Server: Or from the SUA website: /sua/in-home-ss.aspx

OPI Risk Assessment Tool SDS 287J
The OPI Risk Assessment is used to prioritize OPI services to individual’s at risk for out of home placement. It also identifies individuals with the most need when there is an OPI waiting list (or unable to serve list). (3)(b) It’s also used to gather statistical information for the 04AD – Oregon Association of Area Agencies on Aging and Disabilities to help us better understand and serve our target populations.

OPI Risk Assessment Tool 287J
The top portion of the form Identifies the individual and the risk screening date.

287J Risk Assessment Section 1 - Each question is self explanatory as to scoring. Scores are marked on the right column. As you can tell, the questions are most easily answered in a personal interview with the form in hand at the home visit.

287J Risk Assessment Section 1 continued - The total score should auto fill for Section 1 as you enter the question scores. If this feature is disabled on your form, you will need to calculate by hand.

287J Risk Assessment Section 2 has questions 8 & 9 and the score column should automatically total as you enter the question scores.

287J Risk Assessment At the end of section 2 is a Combined Score Risk Level. Add Sections 1 & 2 For the combined score. The Risk level will be N, L, M, H as above. At the top right of the Risk Assessment form is a place for scores for Section 1, Section 2, the Combined score, and the Risk Level. The section scores and the combined score will auto-fill unless the this feature as somehow been disabled on the form you are using.

287J Risk Assessment Below Section 2, is a segment on Chronic Health Conditions. This information is gathered by the O4AD for statistical purposes. Stats are reported to the Oregon Legislature and help define the people we serve and their needs.

287J Risk Assessment Next are 2 questions, also for statistical purposes, concerning hospitalization and ER visits in the last 6 months. The section titled, Reassessment or Final Disposition (arrow) is used only when a person is leaving the OPI program; failed to go beyond the initial assessment in the application process; or died.

Notice of Privacy Practice MSC 2090
Above you see the top half of the title page of this 5 page form.

Notice of Privacy Practice MSC 2090
Note that this form is dated 2/ Always use the most current form.

Acknowledgement of Receipt of Notice of Privacy Practice MSC 2092
Optional Form Form 2092 is signed by the individual or the legal representative and returned to the OPI worker. This is not a required form for OPI, but serves to verify the 2090 was received.

Note that the 2092, states that the individual has had a chance to ask questions about how their information will be used. The best practice, is for the OPI worker to present the 2090 and the forms at the Home Visit. This provides the opportunity for the individual’s questions to be answered at that time and for the 2092 to be signed. Become familiar with the contents of form 2090 to help you answer questions. The form is well laid out and information is clearly stated.

Note: As stated before, this form is optional. If you are not using the 2092, you must clearly narrate on the case narration that you have given Form 2090, Notice of Privacy Practice to the OPI participant. If you choose to use the 2092, place it in the case file and also narrate you have given Form 2090 and received a signed Form 2092 Acknowledgement.

Form MSC 2099 - Authorization for Disclosure of Information
This form is used when specific information is needed from a third party. This form gives release of specific information from one record holder to a specific person or team of people. You will normally know at the home visit if you need to request additional information. Discuss the form and the information requested. Have the form available to be signed.

The MSC 2099 form is available on the DHS Forms server and can be filled online; but you will most probably have a blank copy with you at the home visit. Individuals should not sign a blank The information needs to be filled out prior to signature. This form has 2 pages and both need to be presented together to the individual.

Form 2099 needs to be filled out in a very specific way
Form 2099 needs to be filled out in a very specific way. Please download Form 2099i – Instructions for Completing the Authorization. The instructions are very clear and specific, and guide you section by section. Please familiarize yourself with these instructions. We will not cover the instructions in this training presentation.

Pause for Questions

OPI Income / Fee Determination SDS 287K
The OPI Fee Determination form guides you through gathering income & deduction amounts to calculate the individual’s Net Monthly Income. The Net Income is used to determine the OPI Fee according to the current OPI Fee Schedule.

287K Income/Fee Determination
Enter the name, Prime number, date, and household size on the form. Next list all income sources (i.e. Social Security, pensions, interest and dividend payments, annuities, railroad retirement, and other income. The form auto calculates the total gross monthly income (1) (b)

Next enter the individual’s allowable medical deductions. They may include: Medicare premiums or other health insurance premiums; doctor visit fees or co-pays; over the counter medications; medical or hospital bills; herbal remedies recommended by licensed health professionals; health care equipment; medical supplies; in-home nursing care, and non- custodial child support (1) (b) (D)

The form will auto fill the total allowable medical deductions. Gross Income, minus the Medical Deductions = Net Monthly Income. It is the Net Monthly Income that is used to determine the OPI percentage to pay (using the most current fee schedule) or the one time fee.

OPI Fees: (1)(a) A One-Time fee is applied to all individuals receiving OPI authorized services who have adjusted income levels at or below the poverty level. All individuals whose annual gross income exceeds the minimum, are charged based on a sliding fee schedule as established by the Department.

OPI Fees: (1)(a) The above rules make it clear that OPI fees are a mandatory feature of the Program, and therefore will always be addressed in the AAA Area Plan. If an applicant to OPI refuses to provide income information, we cannot determine fees, and the applicant cannot meet the Department’s requirement of a fee determination. Note: The OPI Fee Schedule is updated from time to time. Keep up to date and use the newest version found on the SUA website or DHS Transmittal.

OPI Fees: 411-032-0015 (1)(a) & 411-032-0044(d)
Information on how fees for OPI services are billed (invoiced), collected, and utilized is contained in each AAA Area Plan. The Area Plan also contains policy for addressing individual non-payment of fees, including when or if exceptions are made for repayment and when or if fees can be waived in hardship cases.

OPI Fee Schedule Please use the most current Fee Schedule available. Fee schedules are updated by AR – Action Request Transmittals from DHS. Select the correct schedule column for the number in household. For a household of One, any net income up to $1459 will pay zero percent on the current schedule.

OPI Fee Schedule Net Incomes $1460 and above will have an OPI % fee according to the current schedule. For example: a person with a net income of $ 1800 will pay a 10% OPI fee. At the current HCW rate of $13 per hour, this person will be paying $1.30 an hour for the approved number of OPI in-home hours.

Using the example of a Net monthly income of $1800, the worker would consult the OPI Fee Schedule and enter 10% in the box for OPI Percentage to Pay. If the individual had a lower income and zero % to pay, they would be subject to a $25 one time fee, and the “Yes” box is checked on the form.

After determining either the OPI percentage to pay, or the $25 one time fee, enter the types of services to be billed. In this example the individual is to receive 10 hours Personal Care and 10 hours of Home Care, and a HCW is providing the services at a rate of $13 per hour. Because you previously entered the OPI % to pay, the form self-calculates the maximum to be charged monthly. In this example, the actual cost of personal care is $130, but the individual will be charged $13 (10% of the actual cost). For both personal care hours and home care hours, the maximum monthly fee will be a total of $ This is the amount that the individual will be billed monthly.

Note: The local AAA determines what services are available in your area. Fees for all authorized services (except service coordination and home delivered meals) are charged based on a sliding fee schedule (1)(b) Consult your Area Plan for details.

The last component of this form are the signatures. The OPI worker should sign the form and mail it to the individual for signature and return. Narrate the details of the fee determination including the amount of net income and the fee amounts to be billed.

The information on this form is also used on the OR Access Service Tab, where the % and the fee amount are to be entered. See below:

OPI Service Agreement SDS 287L
Shown above is the top portion of the SDS 287L Service Agreement. The Service Agreement serves as a notice of eligibility & responsibility.

287L OPI Service Agreement
This form cannot be properly filled out unless you have already determined what services are to be provided for this individual, the begin date of the services, and the fees associated with the services. (Refer to form 287K)

The top portion of the form is filled out with the individual’s name, the date approved services begin, the number of people in the household, and the adjusted monthly income (from form 287K )

The bottom portion of the form includes a statement of understanding about either a one-time fee, or the monthly fee to be billed. Consult your Area Plan for details of what can be done, if anything, to help a client in hardship who can’t afford the one time fee.

The table provides a place to list who is providing services, the agreed hours per month, the OPI % (see 287K) , and the individual’s hourly rate (also from 287K).

In this example, personal care is provided by a Home Care Worker. The individual has 10 hours of personal care and pays 10% of the cost. If, for example, the actual cost of the HCW is $13.00 per hour, 10% of $13 is $ So $1.30 is the hourly rate charged the Individual.

In this example, home care is provided by an Agency. The individual has 10 hours of Home Care and pays 10% of the cost. If, for example, the actual cost of the Agency is $18.00 per hour, 10% of $18 is $ So $1.80 is the hourly rate charged the Individual. (Note: Agency rates may be different from HCW rates.)

Also in this example, OPI home delivered meals are provided – 20 meals per month. In the example there is no OPI% because the AAA provides HDM at no cost to the consumer. Check your Area Plan for costs associated with HDM if available in your area. Now the maximum monthly amount is $31.00 for the full 20 hours. The worker signs the form and sends it to the individual for signature.

Pause for Questions

Next we will look at forms used for Home Care Workers (HCW) These forms are only needed if the OPI services include anything done by a HCW: Personal Care, Home Care, Chore Services, or Escort Services SDS 4105 Homecare Worker Notice SDS 598 Task List SDS 354 Worker’s Comp Agreement SDS 546N Service Plan

SDS 4105 Homecare Worker Notice of Authorized Hours & Services
The 4105 is used when a HCW begins working for an individual, or when a HCW’s hours are increased or reduced. It is also used when the services a HCW provides are added or removed. This notice should be provided on or before the date of action.

SDS 4105 Homecare Worker Notice of Authorized Hours & Services
The 2008 OPI Desk Manual p. 51 implies you can use the SDS 4105 or a local equivalent. Due to current agreements with SEIU HCW Union, OPI workers should be using the exclusively to ensure you are meeting all the notice requirement of the agreement.

4105 Homecare Worker Notice The upper left box is for the HCWs name and address. On the upper right you supply the date of the notice and the consumer and OPI worker information.

4105 Homecare Worker Notice The first line of the notice is used when a HCW is authorized to begin working. Enter the effective date and the total number of hours.

4105 Homecare Worker Notice The second line of the notice is used when a HCW’s hours are to be reduced. Enter the effective date and the total number of new hours (after the reduction).

4105 Homecare Worker Notice The third line of the notice is used when a HCW’s hours are to be increased. Enter the effective date and the total number of new hours (after the increase).

4105 Homecare Worker Notice The fourth line of the notice is used when a HCW’s services are to be increased. Enter the effective date and the service(s) added.

4105 Homecare Worker Notice The fifth line of the notice is used when a HCW’s services are to be decreased. Enter the effective date and the service(s) excluded.

4105 Homecare Worker Notice The bottom half of the form gives you an opportunity to explain the reason for the action. Check the box of the reason that applies or select “Other” and write a brief explanation.

4105 Homecare Worker Notice The form includes a note with details about the HCW SEIU Union Bargaining Agreement with the State of Oregon mandating written notification when changes occur. It also explains exceptions (i.e. death of the client).

4105 Homecare Worker Notice HCWs do not have hearing rights to appeal changes to hours or services.

SDS 598N Task List The 598 Task List is developed at the same time you are setting up the Service Plan in Oregon Access. To select tasks for the list, go to the CAPS Service Plan and hit the Provider Detail button.

SDS 598N Task List Then select the 546 Details button:

SDS 598N Task List Next select the Task List button:

SDS 598N Task List Next use the (1)check boxes to select the tasks that apply. Only the selected items will appear on the printed form. Use the (2) scroll bar to access the entire list. When the list is complete check the (3) “Click here to verify…” box. Then select “OK” (4) 2 1 3 4

SDS 598N Task List To print the 598 Task List, go to the ACCESS printer icon. Enter the number of the form (1) and select the print box (2). Then hit the Print button on the bottom (not shown). 1 2

598N Task List This is how the printed 598 Task List will appear: It will auto populate the client and worker information. (Note: The info above is fictional training information – not a real client)

598N Task List The task list also shows the HCW wages (not an accurate current rate above), and lists the tasks selected by the OPI worker. Copies of the 598N go to both the HCW and the employer.

598N Task List There is another version of the 598 Task List on the Forms Server. It looks a bit different and all information is manually entered.

SDS 354 Worker’s Comp Agreement
Homecare workers are eligible for Worker’s Compensation Insurance coverage. The OPI employer would normally provide the insurance, but the Home Care Commission of Oregon (HCC) has obtained insurance on behalf of the employer. Form 354 provides authorization and consent for the HCC to complete the Worker’s Comp claims for the OPI client employer. The employer agrees to cooperate with the HCC or the insurance company to process claims. Note: If a client refuses to sign the 354 Agreement, they cannot use a Home Care Worker, but may use an Agency provider.

This form is found both in ACCESS and on the Forms Server.

This form is signed by the client and kept in the case file.

SDS 546N Service Plan This form is found in Oregon ACCESS. Open the individual’s case, and use the printer icon to do a forms search. Enter 546N and the form should auto populate all fields with the individual’s personal information and the HCWs information and authorized hours.

546N Service Plan This form is used to authorize payment vouchers to HCWs, and payment to Agency providers.

546N Service Plan The form details the authorized hours and the payment amount. The OPI Worker signs this form as authorization.

546N Service Plan Rates printed on the 546N are pulled from the Access case. Open the Service Plan and select the current assessment. At the bottom select Provider Detail > then 546 Details > then the Service Rates Tab (shown). Use the radio buttons to select either Daily Living (Personal Care); or IADL (Housekeeping). We do not use the 24 hour availability for OPI cases. For both categories enter the dollar amount rate of pay for the provider. Then click “OK”

OPI Application ? No universal OPI application form exists or is required. AAAs respond to inquiries according to their Area Plan and screen the individual for other programs including Medicaid.

OPI Denial Notice ? No universal OPI denial, reduction, or termination notice exists. AAAs describe the process in their Area Plan. Clients may receive a letter of denial, reduction, or termination which includes the grievance procedure; and the individual’s right to an Administrative Review by DHS State Unit on Aging per OAR (4)(c).

Grievance Procedure All AAAs are required to have a written Grievance Procedure or policy, but no universal OPI grievance notice exists. Consult the Area Plan for details. The formal procedure should contain 1.) Opportunity to communicate with management staff, 2.) Specific timeframes 3.) A written outcome at the end of the grievance process, 4.)The option of administrative review with DHS: State Unit on Aging. Desk Manual p. 51

Final Questions?

Oregon Project Independence State Unit on Aging Contacts:
Suanne Jackson AAA Liaison; ADRC State Unit on Aging State of Oregon, DHS, APD 676 Church St NE Salem, OR 97301 Phone:

Oregon Project Independence OPI Module 2 – Forms & Fees

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