reglab/statecodes huggingface dataset:
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 11 - Projects › Section 317:35-11-2 - Poison control services [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 13 Ok Reg 49,
				  eff 6-21-95 (emergency); Added at 13 Ok Reg 2537, eff 6-27-96; Revoked at 19 Ok
				  Reg 136, eff 9-1-01 (emergency); Revoked at 19 Ok Reg 2149, eff
				  6-27-02
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 13 - Member Rights and Responsibilities › Section 317:35-13-1 - Civil rights

Current through Vol. 41, No. 20, July 1, 2024
A person shall not be denied Title XIX or Title XXI benefits
				  or be subjected to discrimination on grounds of race, color, national origin,
				  sex, age or handicap.
Added at 12 Ok Reg 753, eff 1-6-95 through 7-145-95
					 (emergency) ; Added at 12 Ok Reg 3133, eff 7-27-95 ; Amended at 30 Ok Reg 1209,
					 eff 7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 13 - Member Rights and Responsibilities › Section 317:35-13-2 - Courteous and prompt action

Current through Vol. 41, No. 20, July 1, 2024
(a)
Courteous treatment.
It is the responsibility of the staff members
				of the Agency to be courteous and equitable in their dealings with all persons
				applying for and receiving medical services through the Medical Assistance
				program.
(b)
Prompt
				action.
Eligibility determination for Title XIX benefits is to be
				completed within 60 days of the date of application for persons related to the
				disabled group, and within 45 days of the date of application for individuals
				related to all other eligibility groups.
Added at 12 Ok Reg 753, eff 1-6-95 through 7-145-95
					 (emergency) ; Added at 12 Ok Reg 3133, eff 7-27-95 ; Amended at 30 Ok Reg 1209,
					 eff 7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 13 - Member Rights and Responsibilities › Section 317:35-13-3 - Choice of providers

Current through Vol. 41, No. 20, July 1, 2024
Any person requesting help with payment for medical services
				  has free choice of providers who are willing to accept payment from the OHCA
				  and are eligible to receive such payment.
Added at 12 Ok Reg 753,
				  eff 1-6-95 through 7-145-95 (emergency); Added at 12 Ok Reg 3133, eff
				  7-27-95
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 13 - Member Rights and Responsibilities › Section 317:35-13-4 - Release of medical information

Current through Vol. 41, No. 20, July 1, 2024
When a SoonerCare member or an authorized representative of a
				  member, applies for services, explicit consent is given for the OHCA to release
				  information to applicable state or federal agencies, medical providers, or an
				  OHCA designee when the information is needed to provide, monitor or approve
				  medical services or obtain payment of those services. Additionally, a physician
				  may release medical information to the member or an authorized representative
				  of the member upon written request. The physician, in such instance, would be
				  governed by the physician-patient relationship.
Added at 12 Ok Reg 753,
				  eff 1-6-95 through 7-145-95 (emergency); Added at 12 Ok Reg 3133, eff 7-27-95;
				  Amended at 27 Ok Reg 307, eff 11-3-09 (emergency); Amended at 27 Ok Reg 971,
				  eff 5-13-10
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 13 - Member Rights and Responsibilities › Section 317:35-13-5 - Overpayments

Current through Vol. 41, No. 20, July 1, 2024
(a)
Overpayments due to client error or county error.
When it appears
				a medical payment has been made in error because the individual failed to
				provide correct information or the county failed to obtain complete or correct
				information, the county worker prepares a written summary of facts relating to
				such payment and submits it to the DHS State Office, Attention Family Support
				Services Division (FSSD). FSSD will follow up appropriately in cooperation with
				the staff in the OHCA.
(b)
Overpayment due to State Office error, provider error or fiscal agent
				processing error.
When it is determined that an incorrect payment has
				been made due to OHCA error, provider error or fiscal agent processing error,
				the procedures for correcting the payment errors are:
(1) When the OHCA determines an overpayment
				has been made, automatic offset recoupment procedures are processed through the
				claims processing contractor. This process is followed when the overpayment is
				discovered by the OHCA or the fiscal agent.
(2) When the local office receives
				information a medical provider has been overpaid, a memo is sent to the OHCA,
				giving the source of the information and a summary of the situation. The
				overpayment is recovered by the automatic recoupment process through the fiscal
				agent.
(3) When the medical
				provider discovers they have been overpaid, the provider has two options. The
				provider may voluntarily repay the amount to the OHCA. OHCA will process a
				correction through its claims processing system. If the provider does not
				voluntarily refund the amount, but notifies the OHCA, OHCA will initiate a
				recoupment request.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 13 - Member Rights and Responsibilities › Section 317:35-13-6 - Fraud

Current through Vol. 41, No. 20, July 1, 2024
Federal and State laws make it unlawful for persons to make
				  any false statement or misrepresent facts to receive benefits or payments under
				  the Medicaid Program. The worker, employed by the Department of Human Services,
				  is responsible for ensuring each individual who applies for Medicaid is advised
				  of the responsibilities to provide correct information and to report changes in
				  circumstances which may affect his/her eligibility for Medicaid benefits. As
				  each new provider or supplier of medical services is approved, a letter is
				  mailed to him/her from the OHCA advising of the penalties for misrepresentation
				  of fact on claims for Medicaid benefits. When a local office obtains
				  information indicating possible fraud or abuse by a provider, supplier of
				  medical services, or a recipient, a memorandum explaining the circumstances is
				  forwarded to the OHCA Legal Division. This office has the responsibility for
				  any required action on this type of complaint and appropriate referral of the
				  complaint.
Added at 12 Ok Reg 753,
				  eff 1-6-95 through 7-145-95 (emergency); Added at 12 Ok Reg 3133, eff 7-27-95;
				  Amended at 20 Ok Reg 2797, eff 5-26-03 (emergency); Amended at 21 Ok Reg 1324,
				  eff 5-27-04
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 15 - State Plan Personal Care Services › Section 317:35-15-1 - Overview of long-term medical care services; relationship to Qualified Medicare Beneficiary Plus (QMBP), Specified Low-Income Medicare Beneficiary (SLMB), and other SoonerCare services and eligibility

Current through Vol. 41, No. 20, July 1, 2024
(a) Long-term medical care for the
				categorically needy includes:
(1) Care in a
				nursing facility, per Oklahoma Administrative Code (OAC) 317:35-19;
(2) Public and private intermediate care
				facility for individuals with intellectual disabilities (ICF/IID), per OAC
				317:35-9;
(3) Persons age
				sixty-five (65) years or older in mental health hospitals, per OAC
				317:35-9;
(4) Home and
				Community-Based Waiver Services for the Intellectually Disabled, per OAC
				317:35-9;
(5) Home and
				Community-Based Waiver Services for the ADvantage program, per OAC 317:35-17;
				and
(6) State Plan Personal Care
				services, per OAC 317:35-15.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 15 - State Plan Personal Care Services › Section 317:35-15-2 - State Plan Personal Care (SPPC) services

Current through Vol. 41, No. 20, July 1, 2024
(a) SPPC services assist a member in carrying
				out Activities of Daily Living (ADLs) or Instrumental Activities of Daily
				Living (IADLs) directly related to the member's personal care needs. SPPC
				services prevent or minimize physical health regression or deterioration. SPPC
				services require a skilled nursing assessment to:
(1) Assess a member's needs;
(2) Develop a care plan to meet the member's
				identified personal care needs;
(3)
				Manage care plan oversight; and
(4)
				Periodically reassess and update the care plan when necessary.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 15 - State Plan Personal Care Services › Section 317:35-15-3 - Application for State Plan Personal Care (SPPC) services

Current through Vol. 41, No. 20, July 1, 2024
(a)
Requests for SPPC services.
The SPPC application process initiates when an online application is completed
				for SPPC services. A written financial application is not required for an
				applicant who has an active SoonerCare case. A financial application for SPPC
				services is initiated when there is no active SoonerCare case. TheMedicaid
				application is signed by the applicant, parent, spouse, guardian or someone
				acting on the applicant's behalf. Allfinancial eligibility conditions are
				verified and documented in the case record. When currentavailable information
				establishes eligibility, the information may be used by recording source and
				date of information. If the applicant also wishes to apply for a State
				Supplemental Payment, either the applicant or his or her guardian, or a person
				acting on the applicant's behalf, such as an authorized representative or
				power-of-attorney, signs the application form.
(b)
Application date.
The
				application date is when the benefits request is received and entered into the
				electronic system by OKDHS. Exceptions can occur when OKDHS has contracts with
				certain providers who accept and obtain applications and appropriate
				documentation. Once the documentation, for the SooonerCare eligibility
				determination, has been obtained, the contracted provider will forward the
				application and all applicable documentation to either the OKDHS county office
				or the Medicaid Services Unit-ADvantage Administration.
(c)
Eligibility status.
Financial and medical eligibility is established before services can be
				initiated.
Added at 12 Ok Reg 753,
				  eff 1-6-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3133, eff 7-27-95;
				  Amended at 14 Ok Reg 56, eff 4-30-96 (emergency); Amended at 14 Ok Reg 1802,
				  eff 5-27-97; Amended at 17 Ok Reg 2410, eff 6-26-00; Amended at 20 Ok Reg 1958,
				  eff 6-26-03; Amended at 26 Ok Reg 549, eff 2-1-09 (emergency); Amended at 26 Ok
				  Reg 2140, eff 6-25-09
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 15 - State Plan Personal Care Services › Section 317:35-15-4 - State Plan Personal Care (SPPC) services medical eligibility determination

Current through Vol. 41, No. 20, July 1, 2024
(a)
Eligibility.
The Oklahoma Human Services (OKDHS) Health Care
				Management Nurse (HCMN) III determines medical eligibility for SPPC services
				based on the Uniform Comprehensive Assessment Tool (UCAT)and the determination
				that the member has unmet care needs that require personal care assistance.
				SPPC services are initiated to support the regular care provided in the
				member's home. SPPC services are not intended to take the place of regular
				care, general maintenance tasks, or meal preparation provided by natural
				supports, such as spouses or other adults who live in the same household.
				Additionally, SPPC services are not furnished when they principally benefit the
				family unit. To be eligible for SPPC services, the applicant:
(1) Has adequate informal supports. This
				means there is adult supervision that is present or available to contribute to
				care or decision-making ability, as documented on the UCAT. To remain in his or
				her home without risk to his or her health, safety, and well-being, the
				applicant:
(A) Has the decision-making
				ability to respond appropriately to situations that jeopardize his or her
				health and safety, orhas available supports that compensate for his or her lack
				of ability as documented on the UCAT; or
(B) Has his or her decision-making ability,
				lacks the physical capacity to respond appropriately to situations that
				jeopardize health and safety, and an OKDHS HCMN I or II informed him or her of
				potential risks and consequencesof remaining in the home.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 15 - State Plan Personal Care Services › Section 317:35-15-5 - General financial eligibility requirements for State Plan Personal Care

Current through Vol. 41, No. 20, July 1, 2024
Financial eligibility for SPPC is determined using the rules
				  on income and resources according to the eligibility group the member is
				  related to. Income and resources are evaluated on a monthly basis for all
				  members requesting payment for SPPC who are categorically related to Aged,
				  Blind, or Disabled (ABD); maximum countable monthly income and resource
				  standards for individuals related to ABD are found on Oklahoma Human Services
				  (OKDHS) form 08AX001E (Appendix C-1), Schedule VI Qualified Medicare
				  Beneficiary Plus program standards.
Added at 12 Ok Reg 753, eff 1-6-95 through 7-14-95
					 (emergency) ; Added at 12 Ok Reg 3133, eff 7-27-95 ; Amended at 14 Ok Reg 56,
					 eff 4-30-96 (emergency) ; Amended at 14 Ok Reg 1802, eff 5-27-97 ; Amended at
					 17 Ok Reg 2410, eff 6-26-00 ; Amended at 26 Ok Reg 549, eff 2-1-09 (emergency)
					 ; Amended at 26 Ok Reg 2140, eff 6-25-09 ; Amended at 30 Ok Reg 1209, eff
					 7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 15 - State Plan Personal Care Services › Section 317:35-15-6 - Determining financial eligibility of categorically needy individuals

Current through Vol. 41, No. 20, July 1, 2024
Financial eligibility for State Plan Personal Care (SPPC)
				  services for categorically needy individuals is determined as follows:
(1)
Financial eligibility for Modified
				Adjusted Gross Income (MAGI) eligibility groups.
See MAGI eligibility
				rules in Subchapter 6 of this Chapter to determine financial
				eligibility.
(2)
Financial
				eligibility or categorically related to Aged, Blind, and Disabled.
In
				determining income and resources for the member related to ABD, the "family"
				includes the individual and spouse, if any. To be categorically needy, the
				countable income is less than the categorically needy standard as shown on the
				OKDHS form 08AX001E (Appendix C-1), Schedule VI Qualified Medicare Beneficiary
				Plus standard. If a member and his or her spouse cease to live together for
				reasons other than institutionalization or receipt of a Home and Community
				Based Waiver, ADvantage or Developmental Disabilities services, income and
				resources are considered available to each other through the month in which
				they are separated. Mutual consideration ceases with the month after the month
				in which the separation occurs. Any amounts to the spouse after the mutual
				consideration has ended are considered.
(3)
Determining financial eligibility
				for State Plan Personal Care. (SPPC).
For individuals determined
				categorically needy for SPPC, the member will not pay a vendor payment for SPPC
				services.
Added at 12 Ok Reg 753, eff 1-6-95 through 7-14-95
					 (emergency) ; Added at 12 Ok Reg 3133, eff 7-27-95 ; Amended at 14 Ok Reg 56,
					 eff 5-27-97 (emergency) ; Amended at 14 Ok Reg 1802, eff 5-27-97 ; Amended at
					 17 Ok Reg 2410, eff 6-26-00 ; Amended at 19 Ok Reg 136, eff 9-1-01 (emergency)
					 ; Amended at 19 Ok Reg 2149, eff 6-27-02 ; Amended at 20 Ok Reg 1958, eff
					 6-26-03 ; Amended at 20 Ok Reg 2775, eff 7-1-03 (emergency) ; Amended at 21 Ok
					 Reg 2234, eff 6-25-04 ; Amended at 26 Ok Reg 549, eff 2-1-09 (emergency) ;
					 Amended at 26 Ok Reg 2140, eff 6-25-09 ; Amended at 30 Ok Reg 1209, eff
					 7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 15 - State Plan Personal Care Services › Section 317:35-15-7 - Certification for State Plan Personal Care

Current through Vol. 41, No. 20, July 1, 2024
(a)
State Plan Personal Care (SPPC)
				certification period.
The first month of the SPPC certification period
				is the first month the member is determinedfinancially and medically eligible
				for SPPC. When eligibility or ineligibility for SPPC is established, the local
				OKDHS office updates the computer-generated notice and the appropriate notice
				is mailed to the member.
(b)
Financial certification period.
The financial certification period
				for SPPC services is twelve (12) months. Eligibility redetermination is
				completed according to the categorical relationship.
(c)
Medical certification
				period.
A medical certification period of not more than thirty-six (36)
				months is assigned for a member who is approved for SPPC. The certification
				period for SPPC services is based on the Uniform Comprehensive Assessment Tool
				evaluation and clinical judgment of the Oklahoma Human Services HCMN
				III.
Added at 12 Ok Reg 753, eff 1-6-95 through 7-14-95
					 (emergency) ; Added at 12 Ok Reg 3133, eff 7-27-95 ; Amended at 14 Ok Reg 56,
					 eff 4-30-96 (emergency) ; Amended at 14 Ok Reg 1802, eff 5-27-97 ; Amended at
					 15 Ok Reg 1896, eff 3-17-98 (emergency) ; Amended at 16 Ok Reg 1438, eff
					 5-27-99 ; Amended at 17 Ok Reg 2410, eff 6-26-00 ; Amended at 26 Ok Reg 549,
					 eff 2-1-09 (emergency) ; Amended at 26 Ok Reg 2140, eff 6-25-09 ; Amended at 30
					 Ok Reg 1209, eff 7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 15 - State Plan Personal Care Services › Section 317:35-15-8 - Agency State PlanPersonal Care (SPPC) service authorization and monitoring

Current through Vol. 41, No. 20, July 1, 2024
(a) Within ten (10)
				business days of referral receipt for SPPC services, the personal care provider
				agency nurse completes an assessment of the member's personal care service
				needs and completes and submits a person-centered plan based on the member's
				needs to the Oklahoma Human Services (OKDHS) Health Care Management Nurse
				(HCMN) I or II. The plan includes the:
(1)
				Adv/SPPC-Nurse Evaluation;
(2)
				SPPC-Service Planning; and
(3) SPPC
				Member Service Agreement.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 15 - State Plan Personal Care Services › Section 317:35-15-8.1 - Agency State Plan Personal Care services; billing, and problem resolution

Current through Vol. 41, No. 20, July 1, 2024
The ADvantage Administration (AA) certifies qualified
				  personal care provider agencies and facilitates the execution of the agencies'
				  SoonerCare(Medicaid) contracts on the Oklahoma Health Care Authority's
				  (OHCA)behalf. OHCA checks the list of providers barred from
				  Medicare/SoonerCare(Medicaid) participation to ensure that the personal care
				  services agency is not listed.
(1)
Payment for State Plan Personal Care (SPPC).
Payment for SPPC
				services is made for care provided in the member's own home or in other
				limitedliving arrangement types, per Oklahoma Administrative Code (OAC)
				317:35-15-2(b)
				(1 through 4).
(A)
Provider agency
				use.
To provide SPPC services, an agency must be licensed by the
				Oklahoma State Department of Health, meets certification standards identified
				by Oklahoma Human Services (OKDHS), and possesses a current
				SoonerCare(Medicaid) contract.
(B)
Reimbursement.
SPPC services payment on a member's behalf is made
				according to the service type and number of authorized service units.
(i) The amount paid to provider agencies for
				each service unit is determined according to established SoonerCare (Medicaid)
				rates for the personal care services. Only authorized units contained in each
				eligible member's individual plan are eligible for reimbursement. Provider
				agencies serving more than one member residing in the same residence ensure the
				members'plans combine units in the most efficient manner to meet the needs of
				all eligible persons in the residence.
(ii) SPPC services payment is for tasks
				performed in accordance with the authorized care planper OAC
				317:30-5-951.
				Payment for personal care skilled nursing service is made on the member's
				behalf for assessment, evaluation, and associated service planning per nursing
				visit.
(iii) SPPC service time is
				documented through Electronic Visit Verification System (EVV), previously known
				as Interactive Voice Response Authentication (IVRA) system, when services are
				provided in the home.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 15 - State Plan Personal Care Services › Section 317:35-15-9 - Financial eligibility redetermination for State Plan Personal Care

Current through Vol. 41, No. 20, July 1, 2024
The Oklahoma Human Services social services specialist
				  completes a financial eligibilityredetermination before the end of the
				  certification period. A notice is generated only if there is a change affecting
				  the member's financial eligibility.
Added at 12 Ok Reg 753,
				  eff 1-6-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3133, eff 7-27-95;
				  Amended at 14 Ok Reg 56, eff 4-30-96 (emergency); Amended at 14 Ok Reg 1802,
				  eff 5-27-97; Amended at 15 Ok Reg 25, eff 9-18-97 (emergency); Amended at 15 Ok
				  Reg 1554, eff 5-11-98; Amended at 26 Ok Reg 549, eff 2-1-09 (emergency);
				  Amended at 26 Ok Reg 2140, eff 6-25-09
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 15 - State Plan Personal Care Services › Section 317:35-15-11 - Case transfer between categories [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg 753,
				  eff 1-6-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3133, eff 7-27-95;
				  Amended at 14 Ok Reg 56, eff 4-30-96 (emergency); Amended at 14 Ok Reg 1802,
				  eff 5-27-97; Amended at 15 Ok Reg 25, eff 9-18-97 (emergency); Amended at 15 Ok
				  Reg 1554, eff 5-11-98; Amended at 17 Ok Reg 2410, eff 6-26-00; Revoked at 26 Ok
				  Reg 549, eff 2-1-09 (emergency); Revoked at 26 Ok Reg 2140, eff
				  6-25-09
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 15 - State Plan Personal Care Services › Section 317:35-15-12 - Case changes

Current through Vol. 41, No. 20, July 1, 2024
Any time there are changes affecting the State Plan Personal
				  Care case eligibility, computer generated notices are issued.
Added at 12 Ok Reg 753,
				  eff 1-6-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3133, eff 7-27-95;
				  Amended at 14 Ok Reg 56, eff 4-30-96 (emergency); Amended at 14 Ok Reg 1802,
				  eff 5-27-97
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 15 - State Plan Personal Care Services › Section 317:35-15-13 - Personal Care contractor; billing, training, and program administration [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 12 Ok Reg 753,
				  eff 1-6-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3133, eff 7-27-95;
				  Amended at 14 Ok Reg 56, eff 4-30-96 (emergency); Amended at 14 Ok Reg 1802,
				  eff 5-27-97; Amended at 15 Ok Reg 25, eff 9-18-97 (emergency); Amended at 15 Ok
				  Reg 718, eff 12-15-97 (emergency); Amended at 15 Ok Reg 1554, eff 5-11-98;
				  Amended at 17 Ok Reg 2410, eff 6-26-00; Amended at 18 Ok Reg 2969, eff 5-17-01;
				  Amended at 19 Ok Reg 1071, eff 5-13-02; Revoked at 20 Ok Reg 1069, eff 4-1-03
				  (emergency); Revoked at 20 Ok Reg 1943, eff
				  6-26-03
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 15 - State Plan Personal Care Services › Section 317:35-15-13.1 - Individual personal care assistant (IPCA) service management

Current through Vol. 41, No. 20, July 1, 2024
(a) An Individual
				Personal Care Assistant (IPCA) may be utilized to provide SPPC services when it
				is documented to be in the member's best interest to have an IPCA, or when
				there are no qualified personal care provider agencies available in the
				member's local area. Oklahoma Health Care Authority (OHCA) checks the list of
				providers barred from Medicare/Medicaid participation to ensure the IPCA is not
				listed.
(b) After SPPC services
				eligibility is established, and prior to implementation of SPPC services using
				an IPCA, the OKDHS Health Care Management Nurse I or II reviews the care plan
				with the member and IPCA and notifies them to begin SPPC services delivery. The
				OKDHS HCMN I or II maintains the original care plan and forwards a copy to the
				selected IPCA and member within one (1) business day of approval
				receipt.
(c) The HCMN I or II
				contacts the member within five (5) business days to ensure services are in
				place and meeting the member's needs. The HCMN I or II also monitors the care
				plan for members with an IPCA. For any member receiving SPPC services utilizing
				an IPCA, the OKDHS HCMN I or II makes a home visit at least every six(6) months
				beginning within ninety (90) calendar days from the date of service initiation.
				OKDHS HCMN I or II assesses the member's satisfaction with his or her SPPC
				services and evaluates the care plan for adequacy of goals and units allocated.
				Requests for changes in the units authorized in the care plan are approved by
				the HCMN III prior to implementation.
Added at 20 Ok Reg 1069,
				  eff 4-1-03 (emergency); Added at 20 Ok Reg 1943, eff 6-26-03; Amended at 24 Ok
				  Reg 95, eff 8-2-06 (emergency); Amended at 24 Ok Reg 945, eff
				  5-11-07
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 15 - State Plan Personal Care Services › Section 317:35-15-13.2 - Individual personal care assistants (IPCA) provider contractor; billing, training, and problem resolution

Current through Vol. 41, No. 20, July 1, 2024
While the Oklahoma Health Care Authority (OHCA) is the
				  contractor authorized under federal law, the Oklahoma Human Services (OKDHS)
				  Health Care Management Nurse (HCMN) I or II initiates initial contracts with
				  eligible members to provide SPPC services per Oklahoma Administrative Code
				  (OAC)
				  317:35-15-2.
				  OHCA is responsible for IPCA contract renewal.
(1)
IPCA payment.
Payment for
				SPPC services is made for care provided in the member's own home or in other
				limited types of living arrangements per OAC
				317:35-15-2(b)(1)
				through (4). SPPC services may not be
				approved when the member lives in the Personal Care Assistant's (PCA) home,
				except with the approval of OKDHS Community Living, Aging and Protective
				Services.
(A)
Reimbursement.
Personal care payment for a member is made according to the number of personal
				care units identified in the service plan.
(i) The amount per unit paid to individual
				contractors is determined according to the established rates. A service plan is
				developed for each member in the home andservice units are assigned to meet
				each member's needs. The service plans combine units efficiently to meet all
				eligible members needs in the household.
(ii) From the total amounts the IPCAbills in
				(i) of this subparagraph, OHCA, acting as agent for the member-employer,
				withholds the appropriate FICA tax percentage and sends it to the Internal
				Revenue Service as the individual contractor's contribution toward Social
				Security coverage. To ensure theSocial Security account is credited, the
				individual contractor's Social Security number is entered correctly on each
				claim.
(iii) The contractor payment
				fee covers all SPPC services included on the service and care plans the OKDHS
				HCMN I or II develops. Payment is only made for eligible members' direct
				services and care. The OKDHS HCMN III, authorizes the number of service units
				the member receives.
(iv) A member
				may select more than one(1) IPCA. The service and care plan indicates when this
				is necessary.
(v) The IPCA may
				provide SoonerCare SPPC services for several households during one(1) week as
				long as the daily number of paid service units does not exceed eight(8) hours,
				thirty-two (32) units per day. Total weekly hours cannot exceed forty (40),
				one-hundred and sixty (160) units.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 15 - State Plan Personal Care Services › Section 317:35-15-14 - Billing procedures for State Plan personal care

Current through Vol. 41, No. 20, July 1, 2024
Billing procedures for State Plan Personal Care (SPPC)
				  services are contained in the Oklahoma Medicaid Management Information Systems
				  (OKMMIS) Billing and Procedure Manual. Questions regarding billing procedures
				  that cannot be resolved through studying the manual are referred to the
				  Oklahoma Health Care Authority (OHCA). SPPC contractors bill on CMS-1500 claim
				  form. OHCA provides instructions to a contracted Individual Personal Care
				  Assistant (IPCA) forclaim completion at the contractor's orientation. The
				  contracted provider submits a claim for each member. The contracted provider
				  prepares claims for services provided and submits the claims to the fiscal
				  agent responsible for ensuring claims are properly completed. All personal care
				  contractors must have a unique provider number. New contracted providers are
				  mailed the provider number after being placed on the claims processing
				  contractor's provider file. All services provided in the member's home,
				  including Personal Care and Nursing, and all work completed in the provider's
				  office, are documented through the Electronic Visit Verification (EVV) system.
				  The EVV system provides alternate backup solutions if the automated system is
				  unavailable; however, in the event of an EVV system failure, the provider
				  documents time in accordance with internal provider agency policy and
				  procedures backup plan. This documentation is sufficient to account for both
				  in-home and in-office services. The provider agency's backup procedures are
				  only permitted when the EVV system is unavailable.
Added at 12 Ok Reg 753,
				  eff 1-6-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3133, eff 7-27-95;
				  Amended at 14 Ok Reg 56, eff 4-30-96 (emergency); Amended at 14 Ok Reg 1802,
				  eff 5-27-97; Amended at 15 Ok Reg 25, eff 9-18-97 (emergency); Amended at 15 Ok
				  Reg 1554, eff 5-11-98; Amended at 20 Ok Reg 1958, eff 6-26-03; Amended at 26 Ok
				  Reg 558, eff 2-1-09 (emergency); Amended at 26 Ok Reg 2149, eff
				  6-25-09
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 15 - State Plan Personal Care Services › Section 317:35-15-15 - Social services referral

Current through Vol. 41, No. 20, July 1, 2024
In many situations, members receiving medical services
				  through SoonerCare (Medicaid) need social services. The OKDHS HCMN I or II may
				  make referrals for social services to the OKDHS social services specialist
				  (SSS) in the local office. In addition to these referrals, amember, or another
				  individual acting on the member's behalf, may initiate a social services
				  request.
(1) OKDHS SSS provides the
				indicated services, or makes referrals to the appropriate outside resources if
				the services are not available within OKDHS.
(2) OKDHS SSS provided services:
(A) Enable members to attain or maintain good
				physical and mental health;
(B)
				Assist members who receive care outside their own homes in planning for and
				returning to their own homes or to other alternate care;
(C) Encourage the development and maintenance
				of family and community interests and ties;
(D) Promote member's maximum independence in
				managing their own affairs;
(E)
				Include protective services that evaluate the need for and arrange
				guardianship; and
(F) Offer family
				planning services, including family assistance in acquiring means to
				responsible parenthood. Services are offered in making the necessary referral
				and follow-up.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 16 - State Plan Personal Care Services for Expansion Adults, TEFRA Eligible Children and Certain Magi Populations › Section 317:35-16-1 - State Plan Personal Care Services (SPPC)

Current through Vol. 41, No. 20, July 1, 2024
(a) The State Plan
				Personal Care services described in this subchapter are available to the
				following:
(1) Expansion adults;
(2) TEFRA children; and
(3) Certain MAGI populations (children) who
				qualify under the EPSDT program.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 16 - State Plan Personal Care Services for Expansion Adults, TEFRA Eligible Children and Certain Magi Populations › Section 317:35-16-2 - Determination of medical eligibility for State Plan Personal Care (SPPC) services for Expansion Adults, TEFRA, and certain MAGI populations

Current through Vol. 41, No. 20, July 1, 2024
(a)
Eligibility.
The OHCA Clinical Review team (OHCA nurse) determines
				medical eligibility for SPPC services based on the Uniform Comprehensive
				Assessment Tool (UCAT) Part III and the determination that the member has unmet
				care needs that require personal care assistance. SPPC services are initiated
				to support the regular care provided in the member's home. SPPC services are
				not intended to take the place of regular care, general maintenance tasks, or
				meal preparation provided by natural supports, such as spouses or other adults
				who live in the same household. Additionally, SPPC services are not furnished
				when they principally benefit the family unit. To be eligible for SPPC
				services, the applicant:
(1) Has adequate
				informal supports. This means there is adult supervision that is present or
				available to contribute to care, or decision-making ability, as documented on
				the UCAT Part III. To remain in his or her home without risk to his or her
				health, safety, and well-being, the applicant:
(A) Must have the decision-making ability to
				respond appropriately to situations that jeopardize his or her health and
				safety, or has available supports that compensate for his or her lack of
				ability as documented on the UCAT Part III; or
(B) His or her decision-making ability, lacks
				the physical capacity to respond appropriately to situations that jeopardize
				health and safety, and an OHCA nurse has informed his/her of potential risks
				and consequences of remaining in the home.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 16 - State Plan Personal Care Services for Expansion Adults, TEFRA Eligible Children and Certain Magi Populations › Section 317:35-16-3 - General financial eligibility requirements for State Plan Personal Care

Current through Vol. 41, No. 20, July 1, 2024
Financial eligibility for SPPC is determined using the rules
				  on income and resources according to the eligibility group the member is
				  related to.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 16 - State Plan Personal Care Services for Expansion Adults, TEFRA Eligible Children and Certain Magi Populations › Section 317:35-16-4 - Determining financial eligibility of categorically needy individuals

Current through Vol. 41, No. 20, July 1, 2024
Financial eligibility for State Plan Personal Care (SPPC)
				  services for categorically needy individuals is determined as follows:
(1)
Financial eligibility for Modified
				Adjusted Gross Income (MAGI) eligibility groups.
See MAGI eligibility
				rules in Subchapter 6 of this Chapter to determine financial
				eligibility.
(2)
Determining
				financial eligibility for State Plan Personal Care (SPPC).
For
				individuals determined categorically needy for SPPC, the member will not pay a
				vendor payment for SPPC services.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 16 - State Plan Personal Care Services for Expansion Adults, TEFRA Eligible Children and Certain Magi Populations › Section 317:35-16-5 - Certification for State Plan Personal Care

Current through Vol. 41, No. 20, July 1, 2024
(a)
State
				Plan Personal Care (SPPC) certification period.
The first month of the
				SPPC certification period is the first month the member is determined
				financially and medically eligible for SPPC. When eligibility or ineligibility
				for SPPC is established, OHCA updates the computer-generated notice and the
				appropriate notice is mailed to the member.
(b)
Financial certification
				period.
The financial certification period for SPPC services is twelve
				(12) months. Eligibility redetermination is completed according to the
				categorical relationship.
(c)
Medical certification period.
A medical certification period of
				not more than thirty-six (36) months is assigned for a member who is approved
				for SPPC. The certification period for SPPC services is based on the Uniform
				Comprehensive Assessment Tool evaluation and clinical judgment of the OHCA
				nurse.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 16 - State Plan Personal Care Services for Expansion Adults, TEFRA Eligible Children and Certain Magi Populations › Section 317:35-16-6 - Agency State Plan Personal Care (SPPC) service authorization and monitoring

Current through Vol. 41, No. 20, July 1, 2024
(a) Within ten (10)
				business days of referral receipt for SPPC services, the personal care provider
				agency nurse completes an assessment of the member's personal care service
				needs and completes and submits a person-centered plan based on the member's
				needs to the OHCA nurse. The plan includes the:
(1) Adv/SPPC-Nurse Evaluation;
(2) SPPC-Service Planning; and
(3) SPPC Member Service Agreement.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 16 - State Plan Personal Care Services for Expansion Adults, TEFRA Eligible Children and Certain Magi Populations › Section 317:35-16-7 - Agency State Plan Personal Care services; billing, and problem resolution

Current through Vol. 41, No. 20, July 1, 2024
The ADvantage Administration (AA) certifies qualified
				  personal care provider agencies and facilitates the execution of the agencies'
				  SoonerCare (Medicaid) contracts on the Oklahoma Health Care Authority's (OHCA)
				  behalf. OHCA checks the list of providers barred from Medicare/SoonerCare
				  (Medicaid) participation to ensure that the personal care services agency is
				  not listed.
(1)
Payment for
				State Plan Personal Care (SPPC).
Payment for SPPC services is made for
				care provided in the member's own home or in other limited living arrangement
				types, per Oklahoma Administrative Code (OAC)
				317:35-15-2(b)
				(1 through 4).
(A)
Provider agency
				use.
To provide SPPC services, an agency must be licensed by the
				Oklahoma State Department of Health, meets certification standards identified
				by Oklahoma Human Services (OKDHS), and possesses a current SoonerCare
				(Medicaid) contract.
(B)
Reimbursement.
SPPC services payment on a member's behalf is made
				according to the service type and number of authorized service units.
(i) The amount paid to provider agencies for
				each service unit is determined according to established SoonerCare (Medicaid)
				rates for the personal care services. Only authorized units contained in each
				eligible member's individual plan are eligible for reimbursement. Provider
				agencies serving more than one member residing in the same residence ensure the
				members' plans combine units in the most efficient manner to meet the needs of
				all eligible persons in the residence.
(ii) SPPC services payment is for tasks
				performed in accordance with the authorized care plan per OAC
				317:30-5-951. Payment for
				personal care skilled nursing service is made on the member's behalf for
				assessment, evaluation, and associated service planning per nursing
				visit.
(iii) SPPC service time is
				documented through Electronic Visit Verification System (EVV), previously known
				as Interactive Voice Response Authentication (IVRA) system, when services are
				provided in the home.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 16 - State Plan Personal Care Services for Expansion Adults, TEFRA Eligible Children and Certain Magi Populations › Section 317:35-16-8 - Financial eligibility redetermination for State Plan Personal Care

Current through Vol. 41, No. 20, July 1, 2024
The OHCA nurse reviews the electronic system to confirm
				  member eligibility before the end of the certification period. A notice is
				  generated only if there is a change affecting the member's financial
				  eligibility.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 16 - State Plan Personal Care Services for Expansion Adults, TEFRA Eligible Children and Certain Magi Populations › Section 317:35-16-10 - Case changes

Current through Vol. 41, No. 20, July 1, 2024
(a) Any time there
				are changes affecting the State Plan Personal Care case eligibility, computer
				generated notices are issued.
(b) A
				member has the right to withdraw their request for SPPC services at any time
				during the process, but if the member is determined to meet eligibility under
				another aid category based on information available to the agency during this
				time (as referenced under
				317:35-6-60.1), we are required
				to take action on this regardless of the withdrawal of the request for SPPC
				services.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 16 - State Plan Personal Care Services for Expansion Adults, TEFRA Eligible Children and Certain Magi Populations › Section 317:35-16-11 - Billing procedures for State Plan Personal Care

Current through Vol. 41, No. 20, July 1, 2024
Billing procedures for State Plan Personal Care (SPPC)
				  services are contained in the Oklahoma Medicaid Management Information Systems
				  (OKMMIS) Billing and Procedure Manual. Questions regarding billing procedures
				  that cannot be resolved through studying the manual are referred to the
				  Oklahoma Health Care Authority (OHCA). SPPC contractors bill on CMS-1500 claim
				  form. The contracted provider submits a claim for each member. The contracted
				  provider prepares claims for services provided and submits the claims to the
				  fiscal agent responsible for ensuring claims are properly completed. All
				  personal care contractors must have a unique provider number. New contracted
				  providers are mailed the provider number after being placed on the claims
				  processing contractor's provider file. All services provided in the member's
				  home, including Personal Care and Nursing, and all work completed in the
				  provider's office, are documented through the Electronic Visit Verification
				  (EVV) system. The EVV system provides alternate backup solutions if the
				  automated system is unavailable; however, in the event of an EVV system
				  failure, the provider documents time in accordance with internal provider
				  agency policy and procedures backup plan. This documentation is sufficient to
				  account for both in-home and in-office services. The provider agency's backup
				  procedures are only permitted when the EVV system is unavailable.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 16 - State Plan Personal Care Services for Expansion Adults, TEFRA Eligible Children and Certain Magi Populations › Section 317:35-16-12 - Social services referral

Current through Vol. 41, No. 20, July 1, 2024
In many situations, members receiving medical services
				  through SoonerCare (Medicaid) need social services. If a member, who is
				  eligible for State Plan Personal Care Services through this Subchapter, has a
				  need for social services, the OHCA will process those necessary
				  referrals.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-1 - Overview of long-term medical care services; relationship to Qualified Medicare Beneficiary Plus (QMBP), Specified Low-Income Medicare Beneficiary (SLMB), and other Medicaid (SoonerCare) services eligibility

Current through Vol. 41, No. 20, July 1, 2024
(a) Long-term medical care for the categorically needy includes:
(1) Care in a long-term care facility per Oklahoma Administrative Code (OAC) 317:35-19;
(2) Care in a public or private intermediate care facility for the intellectually disabled (ICF/IID), per OAC 317:35-9;
(3) Care of persons sixty-five (65) years of age and older in mental health hospitals, per OAC 317:35-9;
(4) Home and Community-Based waiver services for persons with intellectual disabilities, per OAC 317:35-9;
(5) Personal Care services, per OAC 317:35-15; and
(6) Home and Community-Based waiver services (ADvantage waiver) for frail elderly, sixty-five (65) years of age and older; and a targeted group of adults with physical disabilities, nineteen (19) to sixty-four (64) years of age and older, who do not have an intellectual disability or a cognitive impairment related to a developmental disability per OAC 317:35-17-3.