The Department reimburses for services provided to individuals residing in a residential care facility or an adult foster home according to the following:

1. (1) Service Payment. The provider must agree to accept an amount determined pursuant to OAR 461-155-0270 for room and board and a service payment determined by the Department pursuant to OAR 411-027-0020 or 411-027-0050 as payment in full for all services rendered to an individual.
2. (2) Unless otherwise specified in this rule, a tiered rate model is paid for all eligible individuals in accordance with the rate schedule or collective bargaining agreement.
3. (3) Service Rates. Service rates are based on an individual's assessed need for services as documented in CA/PS. Service eligibility levels are assigned based on the degree of assistance an individual requires with activities of daily living, instrumental activities of daily living, health related tasks and other activities that must be performed by a provider.

4. (4) Acuity-Based Rate Model.

   1. (a) Adult Foster Homes and Residential Care Facilities will receive payments based on an Acuity-Based Rate Model. The Acuity Based Rate Model is based on an individual’s assessed level of need in Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), cognition, behavior, and health related treatment need as determined by the CA/PS assessment. Each component of the ADL and IADL shall receive points based on the following assessed level of need:

      1. (A) Independent equals 1 point
      2. (B) Minimum Assist equals 2 points
      3. (C) Assist equals 3 points
      4. (D) Substantial Assist equals 5 points
      5. (E) Full Assist equals 6 points

      6. (F) Additional points shall be assigned based if either of the following criteria is met:

         1. (i) Full assist in the components of self-preservation, decision-making, or ability to make self-understood equals 10 points.
         2. (ii) Substantial or full assist in the component of challenging behaviors equals 20 points.
         3. (iii) An individual who meets the criteria in (ii), will only receive an additional 20 points. The points awarded in (i) and (ii) are not combined.
         4. (iv) Complex health related treatment tasks, as documented in the individuals CA/PS, that requires caregiver assistance on a regular basis but less than once per day equals 1 point.
         5. (v) Complex health related treatment tasks, as documented in the individuals CA/PS, at least daily and requires caregiver assistance each time equals 3 points.

   2. (b) Individuals will be placed on payment tiers based on their total score. Tiers are assigned based on the following scores:

      1. (A) Tier 1 equals 0 to 40 points.
      2. (B) Tier 2 equals 41 to 55 points.
      3. (C) Tier 3 equals 56 to 82 points.
      4. (D) Tier 4 equals 83 -106 points.
      5. (E) Tier 5 equals 107 or more points.

   3. (c) Funded Caregiving Hours. For Adult Foster Homes each tier funds one caregiver on duty 24 hours a day and funds additional caregiving hours per day for each individual as follows:

      1. (A) Tier 1 equals 0 hours.
      2. (B) Tier 2 equals 2 hours.
      3. (C) Tier 3 equals 4 hours.
      4. (D) Tier 4 equals 8 hours.
      5. (E) Tier 5 equals 10 hours.
   4. (d) An individual who is eligible for Extended Waiver Eligibility, as defined and authorized in OAR 411-015-0030, is only eligible for Tier 1 payments.

5. (5) Payment Responsibilities.

   1. (a) An individual is entitled to retain a personal allowance plus any income disregards pursuant to OAR 461-160-0620.

   2. (b) An individual is responsible for payment of the room and board amount pursuant to OAR 461-155-0270.

      1. (A) An individual eligible for Medicaid under OAR chapter 410, division 200 and eligible for long term care services under OAR 411-015-0100 living in community-based care facilities may be eligible for room and board assistance if the individual’s gross income is less than the room and board amount defined in OAR 461-155-0270. The Department issues a special needs payment to the facility, on the individual’s behalf, for the difference between the individual’s income and the room and board standard.
      2. (B) An individual eligible for Medicaid under OAR chapter 410, division 200 and receiving room and board assistance must apply for all benefits for which the individual may be eligible to continue to receive the room and board assistance. Individuals must follow all appeal options if applicable.
   3. (c) An individual must contribute any income in excess of the personal allowance, income disregards, and room and board payments to the provider toward the service payment pursuant to OAR 461-160-0610 and OAR 461-160-0620.
   4. (d) The Department issues payment to the provider for the difference between the service payment and the available income of the individual.
6. (6) The provider may not charge the individual, a relative or a representative of the individual, for any costs or items  for which the Department makes payment for.
7. (7) The Department is not responsible for damages to the provider's home, facility or property, or obligations entered into with the individual.

Statutory/Other Authority

ORS 410.070

Statutes/Other Implemented

ORS 410.070

History

APD 12-2026, amend filed 06/18/2026, effective 06/24/2026
APD 23-2025, temporary amend filed 12/29/2025, effective 01/01/2026 through 06/29/2026
APD 9-2018, amend filed 03/28/2018, effective 03/29/2018
APD 20-2017, temporary amend filed 09/29/2017, effective 10/01/2017 through 03/29/2018
APD 33-2014, f. & cert. ef. 9-2-14
APD 4-2014(Temp), f. & cert. ef. 3-20-14 thru 9-16-14
SPD 7-2008, f. 5-29-08, cert. ef. 6-1-08
SDSD 10-2001, f. 12-24-01, cert. ef. 1-1-02, Renumbered from 411-027-0100
SDSD 4-1998, f. 6-25-98, cert. ef. 7-1-98
SDSD 3-1998, f. 2-27-98, cert. ef. 3-1-98