Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-122 - Levels of care

Current through Vol. 41, No. 20, July 1, 2024
(a) This rule sets
				  forth the criteria used to determine whether an individual who is seeking
				  SoonerCare payment for long term care services needs services at the level of
				  Skilled Nursing Facility, or Intermediate Care Facility for Individuals with
				  Intellectual Disabilities (ICF/IID) . The criteria set forth in this Section
				  must be used when determining level of care for individuals seeking SoonerCare
				  coverage of either facility-based institutional long term care services or Home
				  and Community Based Services (HCBS) Waivers.
(b) The level of care provided by a long term
				  care facility or through a HCBS Waiver is based on the nature of the person's
				  needs and the care, services, and treatment required from appropriately
				  qualified personnel. The level of care review is a determination of an
				  individual's physical, mental , and social/emotional status to determine the
				  appropriate level of care required. In addition to level of care requirements,
				  other applicable eligibility criteria must be met.
(1)
Skilled Nursing facility.
Payment is made for the Part A coinsurance and deductible for Medicare covered
				  skilled nursing facility care for dually eligible, categorically needy
				  individuals.
(2)
Nursing
				  Facility.
Care provided by a nursing facility to members who require
				  professional nursing supervision and a maximum amount of nonprofessional
				  nursing care due to physical conditions or a combination of physical and mental
				  conditions.
(3)
Intermediate
				  Care Facility for Individuals with Intellectual Disabilities
. Care for
				  persons with intellectual disabilities or related conditions to provide health
				  and/or habilitative services in a protected residential setting. To qualify for
				  ICF/IID level of care, persons must have substantial functional limitations in
				  three or more of the following areas of major life activity:
(A)
Self-care.
The individual
				  requires assistance, training ,or supervision to eat, dress, groom, bathe, or
				  use the toilet.
(B)
Understanding and use of language.
The individual lacks functional
				  communication skills, requires the use of assistive devices to communicate,
				  does not demonstrate an understanding of requests, or is unable to follow
				  two-step instructions.
(C)
Learning.
The individual has a valid diagnosis of intellectual
				  disability as defined in the Diagnostic and Statistical Manual of Mental
				  Disorders.
(D)
Mobility.
The individual requires the use of assistive devices to
				  be mobile and cannot physically self-evacuate from a building during an
				  emergency without assistive device.
(E)
Self-direction.
The
				  individual is seven (7) years old or older and significantly at risk in making
				  age appropriate decisions or an adult who is unable to provide informed consent
				  for medical care, personal safety , or for legal, financial, habilitative , or
				  residential issues , and/or has been declared legally incompetent. The
				  individual is a danger to himself or others without supervision.
(F)
Capacity for independent
				  living.
The individual who is seven (7) years old or older and is unable
				  to locate and use a telephone, cross the street safely , or understand that it
				  is unsafe to accept rides, food , or money from strangers . Or an adult who
				  lacks basic skills in the areas of shopping, preparing food, housekeeping , or
				  paying bills.