Summary
Medicaid’s rules, benefits and name can all vary by state. In Oregon, Medicaid is called the Oregon Health Plan. This article focuses on Oregon Medicaid Long Term Care for seniors, which will pay for care in a nursing home, a beneficiary’s home and other settings through one of three programs – Nursing Home Medicaid, HCBS Waivers or ABD Medicaid. This is different from regular Medicaid, which is for financially needy people of all ages.
The Oregon Health Plan (Oregon Medicaid) will cover the cost of long-term care in a nursing home for financially limited Oregon seniors who require a Nursing Facility Level of Care. Coverage includes payment for room and board, as well as all necessary medical and non-medical goods and services, such as:
Items not covered include a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example) and any care services not considered medically necessary.
Oregon Nursing Home Medicaid beneficiaries are required to give most of their income to the state to help cover care expenses. They are only allowed to keep a “personal needs allowance” (PNA) of $77.14/month, which can be spent on personal items such as clothes, snacks, books, haircuts, flowers, etc. They can also keep enough of their income to make Medicare premium payments if they are “dual eligible,” and enough to make any Medicaid-approved spousal income allowance payments to financially needy spouses who are not Medicaid applicants or recipients.
Oregon Nursing Home Medicaid is an entitlement. This means all qualified applicants are guaranteed by law, aka “entitled,” to receive benefits without wait. However, not all nursing homes accept Medicaid, and those that do may not have any available spaces when you or your loved one needs care. So, eligible applicants are guaranteed nursing home coverage without wait, but they are not guaranteed coverage in any facility they choose.
Oregon Home and Community Based Services (HCBS) Waivers will pay for long-term care services and supports that help financially limited Oregon seniors who require a Nursing Facility Level of Care remain, or return to, living in the community instead of living in a nursing home. The word “waiver” means something like voucher in this instance. Think of it as a voucher that will pay for long-term care services for Oregon residents who live in their home, the home of a loved one, an adult foster care home or an assisted living residence. While Oregon’s HCBS Waivers programs will cover some long-term care services and supports in those settings, it will not cover room and board costs such as mortgage payments, rent, utility bills and food expenses.
The HCBS Waivers that covers long-term care services and supports for Oregon seniors living in the community are the Aged & Physically Disabled (APD) Waiver and the Independent Choices Program (ICP).
1. Aged & Physically Disabled (APD) Waiver
Oregon’s Aged & Physically Disabled (APD) Waiver offers long-term care benefits to Oregon Medicaid beneficiaries who require a Nursing Facility Level of Care but live in their home, the home of a loved one, an adult foster care home or an assisted living residence. The APD Waiver also helps Oregon Medicaid beneficiaries who live in a nursing home relocate to any of those settings in the community. While the APD Waiver will pay for services in any of those settings, as well as relocation to them, it will not cover their room and board costs.
APD Waiver benefits include home modification, meal delivery, housekeeping services, personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting). For beneficiaries who are moving out of a nursing home and returning to the community, the APD Waiver will cover transitional expenses like moving fees, security deposits and essential furnishings.
Unlike Nursing Home Medicaid, the APD Waiver is not an entitlement. Remember, entitlement in this case means eligible applicants are guaranteed by law to receive benefits. Instead, the APD Waiver has a limited number of enrollment spots (about 39,400 per year as of 2023), and once those spots are full additional applicants are placed on a waitlist.
2. Independent Choices Program (ICP)
Oregon’s Independent Choices Program (ICP) provides a healthcare budget and the ability to select long-term care benefits and caregivers of their choice (including spouses and family members) to Oregon seniors who require a Nursing Facility Level of Care but live in their own home or the home a loved one.
The monthly consumer-directed care budget is based on the needs and circumstances of the ICP participant, and a service plan with approved goods and services is created with the help of a case manager. These goods can include home modifications (a wheelchair ramp, for example), vehicle modifications, assistive technology and any item that facilitates independent living (like a microwave oven or an easy-access washing machine). The services include personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and the Instrumental Activities of Daily Living (shopping, cooking, cleaning, medication management, etc.).
Friends and family members, including spouses and adult children, can be hired as caregivers through ICP as long as they are age 18+, pass a background check and are capable of completing the assigned tasks. ICP beneficiaries are the “employer” and responsible for setting the caregiver pay rate, issuing payments, withholding taxes and all other financial matters associated with the caregiver, who is formally called the “employee provider.” However, ICP beneficiaries can also use some of their budget to pay for a financial services agency to handle those responsibilities. ICP beneficiaries who can’t make their own care decisions can choose a representative to make decisions for them, although this representative can not also be the caregiver / “employee provider.”
The Independent Choices Program had approximately 2,600 enrollment spots per year as of 2023. Once those spots are full additional applicants are placed on a waitlist.
Oregon’s Aged, Blind, and Disabled (ABD) Medicaid provides healthcare coverage and long-term care services and supports to Oregon residents with limited financial resources who are aged (age 65+), blind or disabled and live in the community. ABD Medicaid can sometimes be referred to as regular Medicaid for seniors, but it should not be confused with the regular Medicaid that is available to financially needy people of all ages. ABD Medicaid is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive healthcare coverage without wait. Access to long-term care benefits via ABD Medicaid depends on the availability of funds, programs and caregivers in the area where the beneficiary lives.
Oregon ABD Medicaid beneficiaries can receive long-term care services and supports through four programs:
1. State Plan Personal Care (SPPC)
Oregon’s State Plan Personal Care (SPPC) program provides long-term care benefits to elderly Oregon ABD Medicaid beneficiaries who live in their own home or the home of a loved one and require at least monthly help with one or more of the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) or the Instrumental Activities of Daily Living (shopping, cooking, cleaning, medication management, scheduling, transportation, etc.). SPPC applicants are not allowed to need a Nursing Facility Level of Care.
SPPC program benefits include up to 20 hours per week of personal care assistance with the Activities of Daily Living or Instrumental Activities of Daily Living. These benefits can be provided by a licensed caregiver found through the Oregon Homecare Commission Registry, or the SPPC beneficiary can self-direct their care and select a caregiver of their choice, including friends and relatives. Spouses, however, can not be hired as caregivers under the SPPC program. These self-directed caregivers, who are formally called “homecare workers” in the SPPC program, must be 18+ years old, be able to complete their assigned tasks, pass a background check and attend a homecare worker orientation. The financial aspects of employing the homecare worker (making payments, withholding taxes, etc.) is handled by the state.
Like ABD Medicaid itself, the SPPC program is an entitlement, which means all eligible applicants are guaranteed by law to receive benefits. SPPC is sometimes called PC20, which is short for personal care 20 hours per month.
2. K Plan
Oregon’s K Plan, which is more formally known as the Community First Choices Option, provides long term care benefits to elderly Oregon residents (age 65+) who require a Nursing Facility Level of Care, but live in their own home, the home of a loved one, an adult foster care home, an assisted living residence or a memory care facility. While the K Plan will cover some services in all of those settings, it will not cover room and board costs. The Client Assessment and Planning System is used to determine if a Nursing Facility Level of Care is necessary for K Plan applicants. The system takes into account an applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and the Instrumental Activities of Daily Living (such as shopping, housekeeping, laundry, medication management), as well as their cognitive capabilities.
K Plan benefits include nursing services, adult day care, meal delivery, home modifications, assistive technology and personal care assistance with the Activities of Daily Living and the Instrumental Activities of Daily Living. These benefits can be provided by a licensed caregiver, or K Plan participants have the option to self-direct their care and hire a friend or family member to provide certain services, like personal care assistance with the Activities of Daily Living. Spouses, however, can not be hired as a K Plan caregiver.
The K Plan is an entitlement, which means that all eligible applicants are guaranteed by law to receive benefits. Although the K Plan is administered through Oregon’s ABD Medicaid plan, it has more lenient financial limits than the limits required to receive ABD Medicaid healthcare. In other words, an individual may be financially eligible for long-term care services through the K Plan but not financially eligible for healthcare through ABD Medicaid. The exact dollar-amount differences are detailed below in the Oregon Aged, Blind, and Disabled Medicaid Eligibility Criteria section.
3. Consumer-Employed Provider (CEP) Program
Oregon’s Consumer-Employed Provider (CEP) Program provides long term personal care assistance to Oregon seniors who require a Nursing Facility Level of Care but live in their own home or the home of a loved one. The Client Assessment and Planning System is used to determine if a Nursing Facility Level of Care is necessary for CEP Program applicants. The system takes into account an applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and the Instrumental Activities of Daily Living (such as shopping, housekeeping, laundry, medication management), as well as their cognitive capabilities.
CEP benefits include up to 40 hours per week of housekeeping services, medication management, health-related tasks (i.e. insulin injections, blood sugar testing, wound care) and personal care assistance with cognitive functions and the Activities of Daily Living. CEP Program participants can find a licensed caregiver through the Oregon Homecare Commission Registry, or they have the option to self-direct their care by selecting a caregiver of their choice. Friends and family members can be hired as CEP caregivers (who are formally called “homecare workers”) as long as they are 18+ years old, able to complete their assigned tasks, pass a background check and attend a homecare worker orientation. Spouses can also be hired as CEP caregivers through the Spousal Pay Program, which is part of CEP. The financial aspects of employing the homecare worker (making payments, withholding taxes, etc.) is handled by the state.
The CEP Program is an entitlement, which means that all eligible applicants are guaranteed by law to receive benefits. Although the CEP Program is administered through Oregon’s ABD Medicaid plan, it has higher (more lenient) financial limits than the financial limits required to receive ABD Medicaid healthcare (as opposed to long term care services and supports). In other words, an individual may be financially eligible for long term care services through the CEP Program but not financially eligible for healthcare through ABD Medicaid. The exact dollar-amount differences are detailed below in the “Oregon Aged Blind and Disabled Medicaid Eligibility Criteria” section.
4. Program of All-Inclusive Care for the Elderly (PACE)
Oregon residents who are age 55 or older and have ABD Medicaid can cover their medical, social service and long-term care needs with one comprehensive plan and delivery system using the Program of All-Inclusive Care for the Elderly (PACE). PACE program participants are required to need a Nursing Facility Level of Care, but they must live in the community. Oregon’s PACE programs can be used by people who are “dual eligible” for Medicaid and Medicare, and it will coordinate the care and benefits from those two programs into one plan. PACE also administers vision and dental care, and PACE day centers provide meals, social activities, exercise programs and regular health checkups and services to program participants. Oregon’s PACE programs are located in Portland (Providence ElderPlace PACE Oregon) and Grants Pass (AllCare PACE). To learn more about PACE, click here.
To be eligible for the Oregon Health Plan (Oregon Medicaid), a person has to meet certain financial and functional (medical) requirements. The financial requirements vary by the applicant’s marital status, if their spouse is also applying for Medicaid, and what program they are applying for – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers or Aged, Blind, and Disabled (ABD) Medicaid Medicaid.
Just For You: The easiest way to find the most current Oregon Health Plan (Oregon Medicaid) eligibility criteria for one’s specific situation is to use our Medicaid Eligibility Requirements Finder tool.
Oregon residents have to meet an asset limit and an income limit in order to be financially eligible for nursing home coverage through the Oregon Health Plan (Oregon Medicaid). For a single applicant in 2024, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.
The 2024 income limit for Oregon Nursing Home Medicaid for a single applicant is $2,829/month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income. However, Oregon Medicaid beneficiaries who reside in nursing homes must give most of their income to the state to help pay for the cost of care. They are only allowed to keep $77.14/month of their income as a “personal needs allowance,” and they are allowed to make Medicare premium payments if they are “dual eligible,” and they can make any allowable spousal income allowance payments to financially needy, non-applicant spouses.
For married applicants with both spouses applying, the 2024 asset limit for nursing home coverage through OHP is a combined $4,000, and the income limit is a combined $5,658/month. For a married applicant with just one spouse applying, the 2024 asset limit is $2,000 for the applicant spouse and $154,140 for the non-applicant spouse, thanks to the Community Spouse Resource Allowance. The income limit is $2,829/month for the applicant, and the income of the non-applicant spouse is not counted.
Plan Ahead: There are alternative pathways to eligibility for Oregon Nursing Home Medicaid applicants who don’t meet their financial limits, such as Medicaid Planning. However, applicants are not allowed to simply give away their assets in order to get under the asset limit. To make sure they don’t, Oregon has a Look-Back Period of five years. This means the state will look back into the previous five years of the Nursing Home Medicaid applicant’s financial records to make sure they have not given away assets.
Functional Requirements
The functional, or medical, criteria for Oregon Nursing Home Medicaid is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that is normally associated with a nursing home. Oregon uses the Client Assessment and Planning System to determine level of care need for Medicaid purposes. The system takes into account an applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and the Instrumental Activities of Daily Living (such as shopping, housekeeping, laundry, medication management), as well as their cognitive capabilities.
Financial Requirements
Oregon residents have to meet an an asset limit and an income limit in order to be financially eligible for Home and Community Based Services (HCBS) Waivers. For a single applicant in 2024, the asset limit for HCBS Waivers in Oregon is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.
The 2024 income limit for HCBS Waivers in Oregon for a single applicant is $2,829/month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, sto4k dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.
For married applicants with both spouses applying, the 2024 asset limit for HCBS Waivers in Oregon is a combined $4,000, and the income limit is a combined $5,658/month. For a married applicant with just one spouse applying, the 2024 asset limit is $2,000 for the applicant spouse and $154,140 for the non-applicant spouse, thanks to the Community Spouse Resource Allowance. The 2024 income limit is $2,829/month for the applicant, and the income of the non-applicant spouse is not counted.
Plan Ahead: There are alternative pathways to eligibility for HCBS Waivers applicants in Oregon who don’t meet their financial limits, such as Medicaid Planning. However, applicants are not allowed to simply give away their assets in order to get under the asset limit. To make sure they don’t, Oregon has a Look-Back Period of five years. This means the state will look back into the previous five years of the Nursing Home Medicaid applicant’s financial records to make sure they have not given away assets.
Functional Requirements
The functional, or medical, criteria for HCBS Waivers eligibility in Oregon is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that is normally associated with a nursing home. To determine if HCBS Waiver applicants require a Nursing Facility Level of Care, Oregon uses the Client Assessment and Planning System (CAPS). The system takes into account an applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and the Instrumental Activities of Daily Living (such as shopping, housekeeping, laundry, medication management), as well as their cognitive capabilities. CAPS uses a scale of 1 (the highest level of need) to 18 (the lowest), and HCBS Waivers applicants must score between 1 and 13 to be eligible. This assessment can also serve to create a service priority level for the applicant, which can be used to determine their potential place on a waitlist.
Financial Requirements
Oregon residents have to meet an asset limit and an income limit in order to be financially eligible for Aged, Blind, and Disabled (ABD) Medicaid through the Oregon Health Plan. For a single applicant in 2024, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.
The 2024 income limit for Oregon ABD Medicaid for a single applicant is $943/month. Almost all income is counted (IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc.) other than COVID-19 stimulus checks and Holocaust restitution payments.
For married applicants, the 2024 asset limit for Oregon ABD Medicaid is a combined $3,000 and the income limit is a combined $1,415/month. These limits apply to married couples with both spouses applying and married couples with just one spouse applying.
In order to be eligible for the long-term care services and supports of Oregon’s K Plan or the Consumer-Employed Provider (CEP) Program, which are both delivered through ABD Medicaid in Oregon, applicants need to meet financial limits that are slightly different than those for healthcare coverage through ABD Medicaid that are described above. The 2024 asset limit for a single applicant for both the K Plan and the CEP Program is $2,000 and the income limit for both programs for single applicants is $2,829/month. For married applicants with both spouses applying for either the K Plan or the CEP Program, the 2024 asset limit is $2,000 per applicant, and the income limit is $2,829/month per applicant. For a married applicant with just one spouse applying to either program, the 2024 asset limit is $2,000 for the applicant spouse and $154,140 for the non-applicant spouse, and the income limit is $2,829/month for the applicant. The income of the non-applicant spouse is not counted.
Plan Ahead: There are alternative pathways to eligibility for ABD Medicaid applicants who are over the asset limit and/or the income limit, such as Medicaid Planning. While Oregon has a Look-Back Period of five years for Nursing Home Medicaid and HCBS Waivers applicants to make sure they don’t give away their assets to get under the limit, the Look-Back Period does not apply to ABD Medicaid applicants. However, ABD applicants should be cautious about giving away their assets. They might eventually need Nursing Home Medicaid or HCBS Waivers, and those programs will deny or penalize the applicant for giving away assets.
Functional Requirements
The only functional requirement for receiving basic healthcare coverage through Oregon’s ABD Medicaid are being aged (65 and over), blind or disabled. For ABD Medicaid applicants who require long-term care services and supports, Oregon will conduct an assessment to determine the kind of services the applicant needs and the state will cover. To be eligible for long-term care services and supports through the K Plan or the Consumer-Employed Provider (CEP) Program, which are both delivered through ABD Medicaid, a Nursing Facility Level of Care is required. Oregon uses the Client Assessment and Planning System to determine if that care requirement is met by K Plan and CEP Program applicants. The system takes into account an applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and the Instrumental Activities of Daily Living (such as shopping, housekeeping, laundry, medication management), as well as their cognitive capabilities.
One’s home is often their most valuable asset, and if counted toward Medicaid’s asset limit, it would likely cause them to be over the limit. However, in many situations the home is not counted against the asset limit:
These rules apply to all three types of Medicaid, with one important exception – ABD Medicaid applicants can disregard the home equity limit. Value does not matter regarding their home’s exempt status. To learn more about the impact of home ownership on Medicaid eligibility, click here.
Oregon Medicaid applicants and recipients may also want to consider protecting their home (and other assets) from estate recovery. States are required by law to try and collect reimbursement for long-term care after the death of Medicaid recipients. They do this through their Medicaid Estate Recovery Programs (MERPs). The rules and regulations regarding estate recovery can vary greatly by state, but all states have a MERP. To learn more about the MERP in Oregon and how you can protect your home from it, click here.
The first step in applying for Oregon Health Plan (Oregon Medicaid) Long Term Care coverage is deciding which of the three Medicaid programs discussed above you or your loved one wants to apply for – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers or Aged, Blind, and Disabled (ABD) Medicaid.
The second step is determining if the applicant meets the financial and functional criteria, also discussed above, for that Long Term Care program. Applying for Oregon Health Plan coverage when not financially eligible will result in the application, and benefits, being denied.
During the process of determining financial eligibility, it’s important to start gathering documentation that clearly details the financial situation for the Oregon Health Plan applicant. These documents will be needed for the official Medicaid application. Necessary documents may include tax forms, Social Security benefits letters, deeds to the home, proof of life insurance and quarterly statements for all bank accounts, retirement accounts and investments. For a complete list of documents you might need to submit with your application, go to our Medicaid Application Documents Checklist.
After financial eligibility requirements are checked and double checked, documentation is gathered, and functional eligibility is clarified, Oregon residents can apply online at Oregon One Eligibility. They can also download, print out and complete a paper application and mail it to OHP Customer Service, P.O. Box 14015, Salem, OR, 97309, or fax it to 503-378-5628.
For step-by-step guides to applying for each of the 3 types of Medicaid Long Term Care, just click on the name: 1) Nursing Home Medicaid 2) HCBS Waivers 3) ABD Medicaid.
Professional Help: Many seniors need support when it comes to Medicaid Long Term Care’s rules, benefits and application process. These are all complicated, constantly changing and vary by state. The best place to get help with Medicaid Long Term Care is through a professional like a Certified Medicaid Planner or an Elder Law Attorney.
After being approved for nursing home coverage through Oregon Medicaid, seniors need to choose which Medicaid-accepting nursing home best meets their needs. Even though Medicaid nursing home coverage is an entitlement, not all nursing homes accept Medicaid, and those that do may not have any available beds. Finding the right residence can be a challenge, especially if you’re looking in a specific location.
Oregon has roughly 120 nursing homes that accept Medicaid, and the majority of them are clustered around the cities along I-5. There are about 60 nursing homes that take Medicaid within 25 miles of Portland. Moving south, there are a dozen or so more around Eugene, nearly 20 in the Salem area and seven near Medford and Grants Pass. The choices narrow on the coast, with four facilities in Coos Bay, for example. The same happens in the eastern half of the state, with just four nursing homes in the Bend area.
TOOLS: Oregon residents can use this facility locator from the Oregon Department of Human Services to find a Medicaid-approved Nursing Home. They can also use Nursing Home Compare, which is a search tool administered by the Centers for Medicare & Medicaid Services (CMS) that has information on more than 15,000 nursing homes across the country.
When you’ve found nursing homes that meet your needs and accept Medicaid, you can start comparing them, if you have multiple options. The search on Nursing Home Compare can be filtered by staffing, health inspections, quality measures and overall rating, which can be a good place to start. The healthcare professionals who work with you are another great source of information. And you can contact your local Area Agency on Aging to find out more information about nursing homes in Oregon.
After doing some research, you or someone you trust should visit any nursing homes you’re considering before making a final decision. Call first to make an appointment for the visit, and arrive with a list of questions, like: How does the facility handle dental and vision care? Does it offer social activities? What is the food like? Who are the staff doctors? CMS has a comprehensive “Nursing home checklist” you can use to evaluate a nursing home while visiting.
CMS data collected from 2019-2022 reveals that Oregon nursing homes averaged 34.1 health deficiencies per year that led to citations, which is much higher than the national average of 25.7. That’s not to say that all nursing homes in Oregon have health standard issues, but some of them certainly do, so it’s important to do your research in that regard before making a final choice. On the other hand, the CMS data also shows that Oregon nursing homes averaged 4.9 staffing hours per resident per day during, which is significantly better than the national average of 3.7.
If you need Medicaid long term care but do not meet the financial eligibility criteria, consider working with a Medicaid Planning professional. These fee-based experts help families structure their finances to become eligible, while streamlining the application process and preserving assets for spouses and family members.
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