Oregon Health Plan (Medicaid) State Plan Personal Care Program (SPPC)

Last updated: October 20, 2021

 

Overview of Oregon’s State Plan Personal Care Program

Oregon’s State Plan Personal Care Program (SPPC) provides in-home personal care assistance for elderly and disabled state residents who require assistance with their activities of daily living (ADLs) and instrumental activities of daily living (IADLs) in order to live independently. ADLs and IADLs include activities such as bathing, personal hygiene, dressing, transitioning (i.e., from the bed to a chair), preparing meals, and light housecleaning. Assistance may be hands-on, but it may also include verbal reminders and prompts, which is especially beneficial for persons with cognitive issues, such as those with Alzheimer’s disease or similar dementias.

The program participant has the option of receiving care assistance via a home care agency provider or self-directing their own care. With the participant-directed option, the program participant is responsible for finding, hiring, managing, scheduling, and firing their own caregiver, which SPPC formally calls a “homecare worker”. SPPC homecare workers must be 18+ years old, capable of performing the required tasks, complete a provider enrollment packet, undergo a background check, and attend a homecare worker orientation. While friends and relatives can be hired as the homecare worker, a spouse cannot be hired to provide care. The financial aspects of being an employer, such as tax withholding and issuing caregiver payments, are handled by the state.

 While spouses cannot be hired to provide care via the State Plan Personal Care Program, they can be hired to provide care via the Independent Choices Program (ICP) and the Spousal Pay Program. Also, unlike with SPPC, an applicant must require a nursing facility level of care.

Program participants who cannot self-direct their own care have to option to elect a representative, including a family member or friend, to do so on their behalf. A representative cannot also be the “homecare worker” (paid caregiver).

Program participants can reside in their own home or the home of a friend or family member. They cannot live in an adult foster care home or an assisted living residence.

SPPC is an entitlement program. This means meeting eligibility requirements equates to immediate receipt of program benefits. Put differently, there is never a wait list to receive personal care assistance via this program.

The State Plan Personal Care (SPPC) Program is a regular state Medicaid program. One might also hear SPPC called PC20, which stands for Personal Care 20 hours / month. Medicaid in Oregon is called the Oregon Health Plan. The Oregon Supplemental Income Program Medical (OSIPM) is the program through the elderly and disabled receive medical care.

 Medicaid Waivers versus State Plan Medicaid
While home and community based services (HCBS) can be provided via a Medicaid waiver or a state’s regular Medicaid plan, HCBS through Medicaid state plans are an entitlement. Put differently, meeting the program’s eligibility requirements guarantees an applicant will receive benefits. On the other hand, HCBS via Medicaid waivers are not an entitlement. Waivers have a limited number of participant enrollment slots, and once they have been filled, a waitlist for benefits begins. Furthermore, HCBS Medicaid waivers require a program participant require the level of care provided in a nursing home, while state plan HCBS do not always require this level of care.

 

Benefits of the State Plan Personal Care Program

Program participants can receive up to approximately 20 hours per month of personal care assistance. Follows is a list of activities with which assistance might be provided.

– Cognitive Assistance – i.e., making decisions, memory, orientation
– Delegated Nursing Tasks
– Health Status Monitoring
– Homemaker Services – i.e., housecleaning, laundry, taking out the garbage
– Toileting / Bowel or Bladder Care
– Meal Preparation
– Medication / Oxygen Management
– Mobility / Transfer / Repositioning
– Personal Hygiene – i.e., bathing, shaving, washing hair, dressing
– Medical Appointment Assistance – i.e., making appointments, arranging transportation

 

Eligibility Requirements for State Plan Personal Care Program

SPPC is for Oregon residents who are elderly (65+) or disabled adults (18+). Additional eligibility criteria are as follows below.

 The American Council on Aging provides a quick and easy Medicaid eligibility test for Oregon seniors requiring ongoing assistance. Start here

 

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 100% of the Federal Benefit Rate (FBR), which increases on an annual basis in January. As of 2021, the income limit for a single applicant is $794 / month. Married couples, regardless of if one or both spouses are applicants, can have a monthly income up to $1,191.

 While many home and community based services Medicaid programs allow a non-applicant spouse to retain a larger portion of a couple’s income and assets, Oregon’s State Plan Personal Care Program does not. In contrast, Oregon’s K Plan / Community First Choice Option does allow a non-applicant spouse a monthly maintenance needs allowance from his/her applicant spouse and a community spouse resource allowance.

Assets
In 2021, the asset limit is $2,000 for a single applicant. For married couples, the asset limit is slightly higher at $3,000. This hold true whether one or both spouses are applicants.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

While there is a 60-month look back rule in which Medicaid checks past asset transfers of those applying for nursing home Medicaid or home and community based services via a Medicaid waiver, it is thought this is not relevant for the State Plan Personal Care Program. In other words, the look back period is not applicable.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our spend down calculator.

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for eligibility purposes, OR State Medicaid considers the home exempt (non-countable) in the following circumstances.
– The applicant lives in the home or has “intent” to return to the home.
– The applicant has a disabled or blind child (any age) living in the home.
– The applicant has a minor child (under 21) living in the home.

Unlike many Oregon Medicaid programs that offer long-term care, the SPPC Program does not have a home equity interest limit for home exemption. Home equity interest is the current value of the home minus any outstanding mortgage.

However, Medicaid does have an estate recovery program that follows the death of a beneficiary. Via this program, the state attempts to recover care costs for which was paid during the beneficiary’s lifetime. This reimbursement is often collected through the sale of the deceased beneficiary’s home. Learn more about the potential of Medicaid taking the home here.

 

Medical Criteria: Functional Need

Unlike with many Medicaid long-term care programs, a nursing facility level of care (NFLOC) is not required. In fact, the State Plan Personal Care Program is not available to persons who require a NFLOC. Instead, applicants must have a personal care need, which is demonstrated by requiring assistance at least monthly with one of the following tasks: Basic personal hygiene (i.e., bathing, shaving, dressing, nail care), toileting / bowel or bladder care, mobility / transferring or repositioning, nutrition (i.e., preparing meals, eating / drinking), delegated nursing tasks, or medication / oxygen management. Relevant to some persons with Alzheimer’s disease or a related dementia, cognitive impairments, such as memory loss, lack of focus, and difficulty making plans, can result in one of the above personal care needs. However, a diagnosis of dementia in and of itself does not mean one will meet the functional criteria.

 For more information about long-term care Medicaid in Oregon, click here.

 

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for OR Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

Utilizing Miller Trusts, called income cap trusts in Oregon, is a common strategy used to lower an applicant’s monthly countable income for long-term care Medicaid eligibility. Essentially, “excess” income is deposited into the trust, no longer counting as income. However, it is thought income cap trusts are not permitted for applicants to become income-eligible for the SPPC Program.

When persons have assets over the limits, they can “spend down” excess assets on ones that are exempt (not counted). While this includes purchasing clothing and home furnishings, irrevocable funeral trusts (IFTs) are another option. IFTs are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Annuities, which turn lump sums of cash into a monthly income stream, are also a good option for some persons. However, one must be aware that annuity payments will be counted towards Medicaid’s income limit. There are many alternative options when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid planners are educated in the planning strategies available in Oregon to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, while it is thought that Medicaid’s 60-month look back rule does not apply to the State Plan Personal Care Program, it does apply to nursing home Medicaid and other OR long-term care Medicaid programs. Commonly, persons require more extensive care as time passes, and therefore, it is critical one not violate the look back rule. Therefore, while there are many planning strategies, they should only be implemented with careful planning and well in advance of the need for long-term care. However, there are some workarounds, and Medicaid planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.

 

How to Apply for Oregon’s State Plan Personal Care Program

Before You Apply

Prior to submitting an application for the State Plan Personal Care Program, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid eligibility test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, previous bank statements, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.

 

Application Process

To apply for SPPC, senior and disabled adult applicants should contact their local Area Agency on Aging (AAA) office or Aging and People with Disabilities (APD) office. Contact information by county can be found here. Alternatively, persons can call the Oregon Department of Human Services at 1-800-282-8096.

Additional information about the State Plan Personal Care Program can be found here. Persons can also contact the Aging and Disability Resource Connection (ADRC) of Oregon at 1-855-673-2372. The Oregon Department of Human Services (ODHS) Office of Aging and People with Disabilities (APD) administers the State Plan Personal Care Program.

 

Approval Process & Timing

The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further.

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