reglab/statecodes huggingface dataset:
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, twenty-one (21) to
				sixty-four (64) years of age and older, who do not have an intellectual
				disability or a cognitive impairment related to a developmental disabilityper
				OAC
				317:35-17-3.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-2 - Level of care medical eligibility determination

Current through Vol. 41, No. 20, July 1, 2024
The OKDHS area nurse, or nurse designee, determines medical
				  eligibility for ADvantage program services based on the Uniform Comprehensive
				  Assessment Tool (UCAT) III assessment and the determination that the member has
				  unmet care needs that require ADvantage or NF services to assure member health
				  and safety. ADvantage services are initiated to support the informal care that
				  is being provided in the member's home, or, that based on the UCAT, can be
				  expected to be provided in the members's home upon discharge of the member from
				  a NF or hospital. These services are not intended to take the place of regular
				  care and general maintenance tasks or meal preparation typically shared or done
				  for one another by spouses or other adults and who live in the same household.
				  Additionally, services are not furnished if they principally benefit the family
				  unit. When there is an informal (not paid) system of care available in the
				  home, ADvantage service provision will supplement the system within the
				  limitations of ADvantage Program policy to enable the family and/or significant
				  others to continue caregiving over extended periods. When the ADvantage
				  personal care attendant and member live within the same household, personal
				  care will only be approved by agreement of the interdisciplinary service
				  planning team and OKDHS AA approval that the personal care tasks are consistent
				  with plan goals and have beneficial outcomes for the member.
(1)
Definitions.
The following
				words and terms when used in this subchapter, shall have the following meaning,
				unless the context clearly indicates otherwise:
(A)
"ADL"
means the activities
				of daily living. Activities of daily living are activities that reflect the
				member's ability to perform self-care tasks essential for sustaining health and
				safety such as:
(i) bathing,
(ii) eating,
(iii) dressing,
(iv) grooming,
(v) transferring (includes getting in and out
				of a tub, bed to chair, etc.),
(vi)
				mobility,
(vii) toileting,
				and
(viii) bowel/bladder
				control.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-3 - ADvantage program services

Current through Vol. 41, No. 20, July 1, 2024
(a) The ADvantage program is a Medicaid Home and Community-Based waiver used to finance non-institutional, long-term care services for the elderly and a targeted group of physically disabled adults when there is a reasonable expectation that within a thirty (30) calendar day period, the person's health, due to disease process or disability, would without appropriate services, deteriorate and require long-term care (LTC) facility care to arrest the deterioration. Individuals may not be enrolled in ADvantage for the sole purpose of enabling them to obtain Medicaid eligibility. Eligibility for ADvantage program services is contingent on an individual requiring one (1) or more of the services offered in the waiver, at least monthly, to avoid institutionalization.
(b) The number of individuals who may receive ADvantage services is limited.
(1) To receive ADvantage program services, individuals must meet one of the categories in (A) through (D) of this paragraph. He or she must:
(A) Be sixty-five (65) years of age or older; or
(B) Be nineteen (19) to sixty-four (64) years of age with a physical disability; or
(C) Be nineteen (19) to sixty-four (64) years of age with a developmental disability, provided he or she does not have a cognitive impairment (intellectual disability); or
(D) Be nineteen (19) to sixty-four (64) years of age with a clinically documented, progressive, degenerative disease process that responds to treatment and previously required hospital or LTC facility level of care services to maintain the treatment regimen to prevent health deterioration.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-3 - ADvantage program services

Current through Vol. 41, No. 20, July 1, 2024
(a) The ADvantage
				program is a Medicaid Home and Community-Based waiver used to finance
				non-institutional, long-term care services for the elderly and a targeted group
				of physically disabled adults when there is a reasonable expectation that
				within a thirty (30) calendar day period, the person's health, due to disease
				process or disability, would without appropriate services, deteriorate and
				require long-term care (LTC) facility care to arrest the deterioration.
				Individuals may not be enrolled in ADvantage for the sole purpose of enabling
				them to obtain Medicaid eligibility. Eligibility for ADvantage program services
				is contingent on an individual requiring one (1) or more of the services
				offered in the waiver, at least monthly, to avoid
				institutionalization.
(b) The
				number of individuals who may receive ADvantage services is limited.
(1) To receive ADvantage program services,
				individuals must meet one of the categories in (A) through (D) of this
				paragraph. He or she must:
(A) Be sixty-five
				(65) years of age or older; or
(B)
				Be twenty-one (21) to sixty-four (64) years of age with a physical disability;
				or
(C) Be twenty-one (21) to
				sixty-four years of age with a developmental disability, provided he or she
				does not have a cognitive impairment (intellectual disability); or
(D) Be twenty-one (21) to sixty-four (64)
				years of age with a clinically documented, progressive, degenerative disease
				process that responds to treatment and previously required hospital or LTC
				facility level of care services to maintain the treatment regimen to prevent
				health deterioration.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-4 - Application for ADvantage services

Current through Vol. 41, No. 20, July 1, 2024
(a)
Application procedures for
				ADvantage services.
If waiver slots are available, the application
				process is initiated by the receipt of a UCAT, Part I or by an oral request for
				services. A written financial application is not required for an individual who
				has an active Medicaid case. A financial application for ADvantage services
				consists of the Medical Assistance Application form. The form is signed by the
				applicant, parent, spouse, guardian or someone else acting on the applicant's
				behalf.
(1) All conditions of financial
				eligibility must be verified and documented in the case record. When current
				information already available in the local office establishes financial
				eligibility, such 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/her guardian must sign the application
				form.
(2) When Medicaid application
				is being made, an assessment of resources must be completed. For applicants of
				the ADvantage waiver, those resources owned by the couple the month the
				application was made determines the spousal share of resources.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-5 - ADvantage program medical eligibility determination

Current through Vol. 41, No. 20, July 1, 2024
The Oklahoma of Human Services OKDHS area nurse or nurse
				  designee, makes the medical eligibility determination utilizing professional
				  judgment, the Uniform Comprehensive Assessment Tool (UCAT), andany
				  otheravailable medical information.
(1) When ADvantage care services are
				requested or the application is received, the:
(A) OKDHS nurse completes the UCAT;
				and
(B) Social services
				specialist(SSS) contacts the applicant within three(3) business days to
				initiate the financial eligibility application process.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-6 - Pre-admission screening [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 17 Ok Reg 2410, eff 6-26-00; Revoked at 21 Ok Reg 2252,
				  eff 6-25-04
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-7 - PASRR screening process [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 3715, eff 5-18-98 (emergency); Amended at 16
				  Ok Reg 1438, eff 5-27-99; Amended at 17 Ok Reg 2410, eff 6-26-00; Amended at 18
				  Ok Reg 277, eff 11-21-00 (emergency); Amended at 18 Ok Reg 1139, eff 5-11-01;
				  Revoked at 21 Ok Reg 2252, eff 6-25-04
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-8 - Level II screen for PAS [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;
				  Revoked at 14 Ok Reg 56, eff 4-30-96 (emergency); Revoked 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 17 - Advantage Waiver Services › Section 317:35-17-8.1 - PASRR appeals process [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 14 Ok Reg 56,
				  eff 4-30-96 (emergency); Added at 14 Ok Reg 1802, eff 5-27-97; Amended at 17 Ok
				  Reg 2410, eff 6-26-00; Revoked at 21 Ok Reg 2252, eff
				  6-25-04
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-9 - General financial eligibility requirements for the ADvantage program

Current through Vol. 41, No. 20, July 1, 2024
Financial eligibility for ADvantage services is determined
				  using the rules on income and resources according to the category to which the
				  individual is related. (See OAC
				  317:35-7-36
				  for categorically related to ABD.) Only individuals who are categorically
				  related to ABD may be served through the ADvantage waiver.
(1) Income, resources and expenses are
				evaluated on a monthly basis for all individuals requesting payment for the
				ADvantage program.
(2) To be
				eligible for long-term care in the ADvantage program, the individual must be
				determined categorically needy according to the OKDHS Appendix C-1, Schedule
				VIII. B. 1. If the individual's gross income exceeds this standard, see OAC
				317:35-5-41.6(a)(6)(B).
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 25 Ok Reg 130,
				  eff 8-1-07 (emergency); Amended at 25 Ok Reg 1257, eff
				  5-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-10 - Determining financial eligibility/categorical relationship for the ADvantage program

Current through Vol. 41, No. 20, July 1, 2024
Financial eligibility for the ADvantage program is determined
				  as follows:
(1)
Financial
				eligibility/categorically related to ABD.
In determining income and
				resources for the individual categorically related to ABD, the "family"
				includes the individual and spouse, if any. If an individual and spouse cease
				to live together for reasons other than institutionalization, 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 which are actually contributed to
				the spouse after the mutual consideration has ended are considered. If the
				individual and spouse cease to live together because of the individual entering
				a nursing facility, see OAC
				317:35-19-21
				to determine financial eligibility.
(A) The
				categorically needy standard on OKDHS Appendix C-1, Schedule VI, is applicable
				for individuals categorically related to ABD.
(B) If the individual is receiving ADvantage
				program services and has received services for 30 days or longer, the
				categorically needy standard in OKDHS Appendix C-1, Schedule VIII. B.1., is
				used. The 30-day requirement is considered to have been met even if it is
				interrupted by a hospital stay or the individual is deceased before the 30-day
				period ends. If the individual does not require services past the 30 days, the
				categorically needy standard in OKDHS Appendix C-1, Schedule VI., is
				used.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-11 - Determining financial eligibility for ADvantage program services

Current through Vol. 41, No. 20, July 1, 2024
Financial eligibility for individuals in ADvantage program
				  services is determined according to whether or not a spouse remains in the
				  home.
(1)
Individual without a
				spouse.
For an individual without a spouse, the following rules are used
				to determine financial eligibility.
(A)
Income eligibility.
To determine the income of the individual, the
				rules in (i) through (iii) of this subparagraph apply.
(i) If payment of income is made to the
				individual and another person(s), the income is considered in proportion to the
				individual's interest.
(ii) If a
				legal instrument exists which specifies terms of payment, income is considered
				according to the terms of the instrument.
(iii) After determination of income, the
				gross income of the individual cannot exceed the categorically needy standard
				in OKDHS form 08AX001E, Schedule VIII. B. 1., to be eligible for ADvantage
				services. If the individual's gross income exceeds that standard, refer to
				SoonerCare rules for establishing a Medicaid Income Pension Trust [OAC
				317:35-5-41.6(a)(6)(B)
				].
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-12 - Certification for ADvantage program services

Current through Vol. 41, No. 20, July 1, 2024
(a)
Application date.
When the
				applicant is determined eligible for ADvantage, his/her certification is
				effective the date that medical and financial eligibility was determined. When
				eligibility or ineligibility for ADvantage program services is established, the
				worker updates the authorization and the computer-generated notice is mailed to
				the member and ADvantage Administration (AA).
(b)
Financial certification
				period
The financial certification period is twelve (12)
				months.
(c)
Medical
				Certification period.
The medical certification period is twelve (12)
				months. Redetermination of medical eligibility by an Oklahoma Department of
				Human Services (DHS) nurse is:
(1) completed
				annually in coordination with the annual reauthorization of the member's
				patient-centered service plan.
(2)
				completed when documentation is received that supports a reasonable expectation
				the member may not continue to meet medical eligibility
				criteria.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-13 - Certification for ADvantage program services [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;
				  Revoked at 14 Ok Reg 56, eff 4-30-96 (emergency); Revoked 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 17 - Advantage Waiver Services › Section 317:35-17-15 - Redetermination of eligibility for ADvantage services

Current through Vol. 41, No. 20, July 1, 2024
(a) The worker must complete a
				redetermination of financial eligibility prior to the end of the certification
				period. A notice is generated only if there is a change which affects the
				member's financial responsibility.
(b) The ADvantage case manager or the OKDHS
				nurse must complete an annual UCAT reassessment that is reviewed for
				redetermination of medical eligibility prior to the end of the certification
				period.
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 25 Ok Reg 2710,
				  eff 7-25-08; Amended at 29 Ok Reg 1172, eff
				  6-25-12
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-16 - Member annual level of care re-evaluation and annual service plan reauthorization

Current through Vol. 41, No. 20, July 1, 2024
(a)
				The ADvantage case manager reassesses the member's needs annually using the
				Uniform Comprehensive Assessment Tool (UCAT), then evaluates the member's
				progress toward person-centered service plan goals and objectives. The
				ADvantage case manager develops the annual person-centered service plan with
				the member and interdisciplinary team and submits the person-centered service
				plan to the ADvantage Administration (AA) for authorization. The ADvantage case
				manager initiates the UCAT reassessment and develops the annual person-centered
				service plan at least forty (40) calendar days, but not more than sixty (60)
				calendar days, prior to theexisting plan's end date. The ADvantage case manager
				provides AA the person-centered service plan reassessment documents no less
				than thirty (30) calendar days prior to theexisting plan's end date. The
				reassessment documents include the person-centered service plan, UCAT, Nursing
				Assessment and Monitoring Tool and supporting documentation.
(b) For medical eligibility reassessment,
				Oklahoma Human Services (OKDHS) recertification nurse reviews the UCAT the
				ADvantage case manager submitted. When policy defined criteria for nursing
				facility LOC cannot be determined or justified from available documentation or
				through direct contact with the ADvantage case manager, the member is referred
				to the local OKDHS nurse. The OKDHS nurse then re-assesses the applicant using
				the UCAT through an electronic format such as a phone and video conference,
				unless there are limiting factors which necessitate a face-to-face assessment.
(1) The OKDHS nurse determines LOC based on
				the assessment's outcome unless the applicant is determined to be medically
				ineligible. In this case, a face-to-face visit is scheduled to either validate
				the electronic format assessment or provide additional documentation to support
				the applicant meeting medical LOC.
(2) Applicants are not medically denied
				access to the waiver solely based on an assessment completed through an
				electronic format.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-17 - Supplemental process for expedited eligibility determination (SPEED) [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 17 Ok Reg 2410, eff 6-26-00; Amended at 20 Ok Reg 1958,
				  eff 6-26-03; Amended at 26 Ok Reg 758, eff 4-1-09 (emergency); Amended at 27 Ok
				  Reg 1507, eff 6-11-10; Revoked at 29 Ok Reg 1172, eff
				  6-25-12
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-19 - Closure or termination of ADvantage services

Current through Vol. 41, No. 20, July 1, 2024
(a)
Voluntary closure of ADvantage
				services.
When the member requests a lower level of care than ADvantage
				services, or agrees that ADvantage services are no longer needed to meet his or
				her needs, a medical level of care decision by the area nurse or nurse
				designee, is not needed. The closure request is completed and signed by the
				member and the ADvantage case manager and sent to the ADvantage Administration
				(AA) to be placed in the member's case record. The AA notifies the Oklahoma
				Department of Human Services (DHS) area nurse or area nurse designee of the
				voluntary closure and effective date of closure. When the member's written
				request for closure cannot be secured, the ADvantage case manager documents in
				the member's case record the reasons for the voluntary termination of services
				and alternatives for services.
(b)
Closure due to financial or medical ineligibility.
The process for
				closure due to financial or medical ineligibility is described in this
				subsection.
(1)
Financial
				ineligibility.
When the local DHS office determines a member does not
				meet financial eligibility criteria, the DHS office notifies the area nurse or
				area nurse designee who closes the member's authorization and notifies the
				member and AA of financial ineligibility by system-generated mail. The AA
				notifies the member's providers of the decision. A medical eligibility
				redetermination is not required when a financial ineligibility period does not
				exceed the medical certification period.
(2)
Medical ineligibility.
When
				the DHS office is notified by the nurse or area nurse designee of a decision
				that the member is no longer medically eligible for ADvantage services, the DHS
				office notifies the member and AA of the decision. Refer to Oklahoma
				Administrative Code (OAC)
				317:35-17-16(d).
				The AA notifies the member's providers of the decision.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-20 - 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; Revoked at 26 Ok Reg 758, eff 4-1-09 (emergency); Revoked at 27 Ok
				  Reg 1507, eff 6-11-10
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-21 - Case changes

Current through Vol. 41, No. 20, July 1, 2024
Any time there are changes which affect the long-term care
				  case, 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 17 - Advantage Waiver Services › Section 317:35-17-21.1 - ADvantage and agency Personal Care provider certification

Current through Vol. 41, No. 20, July 1, 2024
ADvantage Administration (AA) forwards information on all
				  certified ADvantage and Personal Care agency providers providing services in
				  the specific OKDHS area to the area nurse and OKDHS county director. The
				  provider information includes agency name, address, contact person for
				  ADvantage/Personal Care programs, provider number, a list of ADvantage/Personal
				  Care services the provider is certified to deliver, and other information as
				  needed by OKDHS staff to achieve efficient service delivery. The AA certifies
				  ADvantage case managers and case management supervisors. The AA maintains a
				  master registry of certified ADvantage case management supervisors and case
				  managers. Case manager certifications are based on successful completion of
				  ADvantage case management training and demonstration of competency in case
				  management and, for supervisors, case management supervision. As additional
				  providers are certified in an OKDHS area or if a provider loses certification,
				  AA provides appropriate notice to the area nurse and OKDHS county director in
				  counties affected by the certification changes. The OHCA may execute agreements
				  to provide care only with qualified individuals and agencies and facilities
				  which are properly licensed or certified by the state licensing or
				  certification agency and, as applicable, Title XIX certified. The agreement is
				  initiated by application from the individual agency or facility. The agreement
				  expires on a specified date, with termination of the agency license or
				  certification, or automatically terminated on notice, with appropriate
				  documentation, to OHCA that the individual agency or facility is not in
				  compliance with Title XIX (or other federal long-term care) requirements. The
				  AA certifies Title XIX providers of ADvantage services with the exception of
				  pharmacy and medical equipment and supply providers.
Added at 15 Ok Reg 3715,
				  eff 5-18-98 (emergency); Added at 16 Ok Reg 1438, eff 5-27-99; Amended at 26 Ok
				  Reg 758, eff 4-1-09 (emergency); Amended at 27 Ok Reg 1507, eff 6-11-10;
				  Amended at 29 Ok Reg 1172, eff 6-25-12
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-22 - Billing procedures for ADvantage services

Current through Vol. 41, No. 20, July 1, 2024
(a) Billing procedures for long-term care
				medical services are contained in the Oklahoma Medicaid Management Information
				Systems (OKMMIS) Billing and Procedure Manual. Questions regarding billing
				procedures that cannot be resolved through a study of the manual are referred
				to the Oklahoma Health Care Authority (OHCA).
(b) The Oklahoma Department of Human Services
				OKDHS Aging Services (AS) approved ADvantage service plan is the basis for the
				Medicaid Management Information Systems service prior authorization, specifying
				the:
(1) Service;
(2) Service provider;
(3) Units authorized; and
(4) Begin- and end-dates of service
				authorization.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-23 - Disclosure of information on health care providers and contractors

Current through Vol. 41, No. 20, July 1, 2024
In accordance with the requirements of the Social Security
				  Act and the regulations issued by the Secretary of Health and Human Services,
				  the OHCA is responsible for disclosure of pertinent findings resulting from
				  surveys made to determine eligibility of certain providers for home health care
				  providers and contractors under Medicaid. In Oklahoma, the State Department of
				  Health is the agency responsible for surveying home health care providers and
				  contractors to obtain information for use by the Federal Government in
				  determining whether these entities meet the standards required for
				  participation as Medicare and Medicaid providers.
(1) Following its survey of each entity, the
				State Department of Health sends a copy of pertinent materials, showing its
				findings, to the Oklahoma Health Care Authority, Contract Services/Service
				Contracts Operations, who forwards pertinent materials to the DHS county office
				in the county where such facility is located.
(2) Each county office is responsible for
				permitting anyone, who requests permission to do so, to inspect and/or copy
				such findings, if this is done within the county office. Such request to see
				these materials may be specifically related to one provider or may be a request
				to see the available survey materials on all providers. The requests need not
				be made in writing and the person making the request need sign no document in
				order to obtain access to the materials. No one can be given permission to take
				any of these materials from the county office.
(3) These materials are to be filed in an
				administrative file. Only the material requested by the individual is made
				available to him/her. The county director is responsible for devising a plan
				for assuring that all such survey material made available to an individual is
				returned by him/her before he/she leaves the office.
(4) When a new survey report is received on
				an entity, the former survey report on that entity is to be destroyed. A
				permanent file of survey reports is maintained in the OHCA.
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
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-24 - Referral for social services

Current through Vol. 41, No. 20, July 1, 2024
In many situations, social services are needed by adults who
				  are receiving medical services through Medicaid. The OKDHS nurse may make
				  referrals for social services to the social worker in the local office. In
				  addition to these referrals, a request for social services may be initiated by
				  a member or by another individual acting upon behalf of a member.
(1) The social worker is responsible for
				providing the indicated services or for referral to the appropriate resource
				outside the Department if the services are not available within the
				Department.
(2) Among the services
				provided by the social worker are:
(A)
				Services which will enable individuals to attain and/or maintain as good
				physical and mental health as possible;
(B) Services to assist patients who are
				receiving care outside their own homes in planning for and returning to their
				own homes or to other alternate care;
(C) Services to encourage the development and
				maintenance of family and community interest and ties;
(D) Services to promote maximum independence
				in the management of their own affairs;
(E) Protective services, including evaluation
				of need for and arranging for guardianship; and
(F) Appropriate family planning services
				which include assisting the family 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 17 - Advantage Waiver Services › Section 317:35-17-25 - Address Confidentiality Program

Current through Vol. 41, No. 20, July 1, 2024
(a) ADvantage members who are victims of
				domestic violence, sexual assault, or stalking can enroll in the Address
				Confidentiality Program (ACP). The ACP maintains a confidential location by
				providing a substitute address and mail forwarding service when victims
				interact with state and local agencies as per Section
				60.14
				of Title 22 of the Oklahoma Statutes.
(b) The ADvantage Administration (AA), when
				appropriately notified by a currently enrolled ADvantage member or by their
				case manager of enrollment in the ACP, will:
(1) Confirm the member's ACP
				enrollment;
(2) Remove the member's
				physical address from the waiver management database;
(3) Notify the county worker and LTC RN of
				address change;
(4) Maintain a
				confidential file with the physical address of the member; and
(5) Provide the physical address to
				contracted providers when services must be provided to or in the home of the
				member.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-26 - Ethics of Care Committee

Current through Vol. 41, No. 20, July 1, 2024
(a)
				The ADvantage Program Ethics of Care Committee (EOCC) reviews members cases
				when the ADvantage, State Plan Personal Care programs or a provider contracted
				to provide these services determines that a member's identified needs cannot be
				met through the provision of the ADvantage program or State Plan Personal Care
				program and other formal or informal services are not in place or immediately
				available to meet the members health and safety needs. The EOCC is a core group
				of designated representatives from Oklahoma Department of Human Services (DHS)
				Aging Services and Oklahoma Health Care Authority staff and are experts in
				State Medicaid programs, specifically ADvantage waiver and State Plan Personal
				Care, and experienced in addressing member issues as it pertains to policy,
				program, and service delivery.
(b)
				EOCC decisions are predicated upon four (4) guiding principles.
(1)
Sustainability of member
				services.
The overarching concern of EOCC is to ensure that all efforts
				are made to sustain the member's services when possible. EOCC explores options
				and renders a decision that maintains member safety while averting the primary
				issue of concern before the EOCC. This is done while assuring member health and
				safety as outlined in Oklahoma Administrative Code (OAC)
				317:35-17-3(h)
				(1-7).
(2)
Cultural
				competence.
EOCC considers the contextual details of the situation to
				promote needs and interests of ADvantage members and emphasizes understanding
				of the members culture and relevant circumstances.
(3)
Balance and reciprocity.
This assures member health and safety is reliant upon the member's cooperation
				and that of the member's community network, or informal supports. EOCC
				evaluates the viability of the member's resources to sustain health and safety
				independent of Medicaid paid supports when making decisions.
(4)
Education and mitigation.
EOCC uses decision-making processes for determining program appropriateness for
				cases that are problematic or controversial with respect to being able to meet
				member needs within program constraints. The decision-making process engages
				expertise from any area of program function relevant to the case in question
				when necessary. When the case submitted for review is deemed invalid or lacking
				sufficient merit for review, EOCC rescinds the review until the case meets the
				appropriate criteria for review.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-27 - Incident reporting

Current through Vol. 41, No. 20, July 1, 2024
(a)
Reporting requirement.
Certified ADvantage provider staff should
				report critical and non-critical incidents involving the health and welfare of
				ADvantage Waiver members to the Oklahoma Human Services Medicaid Services Unit
				(MSU).
(b)
Critical
				incidents.
Critical incidents are events with potential to cause
				significant risk or serious harm to an ADvantage member's safety or well-being.
				Critical Incidents Reports (CIR) are completed for:
(1) Suspected maltreatment including abuse,
				neglect, or exploitation, per Section 10-103 of Title 43A of the Oklahoma
				Statutes (43A O.S. § 10-103);
(2) Attempted suicide or suicidal ideation
				exhibition;
(3) Unexpected or
				questionable death;
(4) Falls or
				injuries requiring medical attention;
(5) Residence loss due to disaster;
(6) An interruption of needed medical
				supports;
(7) Lost or missing
				members;
(8) A medication error
				requiring medical attention;
(9)
				Use of physical restraints; or
(10)
				Allegations related to Personal Care Assistant (PCA) or Personal Service
				Assistant (PSA).
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 18 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 317:35-18-1 - Programs of All-Inclusive Care for the Elderly (PACE)

Current through Vol. 41, No. 20, July 1, 2024
This chapter establishes the requirements for approved
				  SoonerCare contracted Program of All-Inclusive Care for the Elderly (PACE)
				  providers to provide services to eligible elderly individuals through the
				  Oklahoma Health Care Authority's (OHCA) PACE program.
Added at 23 Ok Reg 2583,
				  eff 6-25-06; Amended at 29 Ok Reg 1189, eff
				  6-25-12
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 18 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 317:35-18-2 - Introduction

Current through Vol. 41, No. 20, July 1, 2024
(a) Programs of
				All-Inclusive Care for the Elderly (PACE) provide home and community-based
				acute and long-term care services to eligible individuals who meet the medical
				requirements for nursing facility care and can be served safely and
				appropriately in the community. PACE is optional in a State Medicaid program.
				PACE is jointly funded and administered by the Centers for Medicare and
				Medicaid Services and the state of Oklahoma. The PACE provider receives a
				monthly capitation payment and is at full risk for the delivery of all
				medically necessary services for the individual. For eligible individuals who
				elect to participate in the PACE program, the OHCA will make capitation
				payments for individuals who are only eligible for Medicaid or who are dually
				eligible for Medicaid and Medicare. OHCA will contract with providers for the
				PACE program in the geographic areas as specified and approved in the provider
				PACE application. The PACE program will provide medically necessary services to
				both American Indian/Alaska Native (AI/AN) and non-Indian Medicaid eligible
				individuals.
(b) Rules applicable
				to the operation of the PACE program are contained in 42 Code of Federal
				Regulations (CFR), Part 460. These regulations, as currently written or amended
				in the future, are incorporated by reference as the rule base for operating the
				PACE program in Oklahoma.
Added at 23 Ok Reg 2583,
				  eff 6-25-06; Amended at 29 Ok Reg 1189, eff
				  6-25-12
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 18 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 317:35-18-3 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The words and terms used in this Subchapter have the
				  following meanings, unless the context clearly indicates otherwise:
(1)
"American Indian/Alaska Native
				(AI/AN)"
means an individual of Native American descent who has or is
				eligible for a Certificate of Degree of Indian Blood (CDIB) card;
(2)
"Capitation"
means the per
				member per month (pmpm) amount that the Oklahoma Health Care Authority pays
				PACE providers for PACE compensable services.
(3)
"Interdisciplinary Team
				(IDT)"
means the team of persons who interact and collaborate to assess
				PACE participants and plan for their care as set forth in
				42 CFR
				460.102. The IDT may also include the PACE
				participant's personal representative or advocate.
(4)
"Participant"
means an
				individual enrolled in a PACE program.
(5)
"Program agreement"
means
				the three-party agreement between the PACE provider, Centers for Medicare &
				Medicaid Services (CMS), and OHCA.
(6)
"Provider"
means the
				non-profitor for-profit entity that delivers required PACE services under an
				agreement with OHCA and CMS.
(7)
"Service area"
means the geographic area served by the provider
				agency, according to the program agreement.
(8)
"State Administering Agency
				(SAA)"
means the Oklahoma Health Care Authority.
Added at 23 Ok Reg 2583,
				  eff 6-25-06; Amended at 29 Ok Reg 1189, eff
				  6-25-12
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 18 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 317:35-18-4 - Provider regulations

Current through Vol. 41, No. 20, July 1, 2024
(a) The provider
				must comply with provisions of this Subchapter, and the regulations in 42 CFR,
				Part 460.
(b) The provider agency
				must be licensed by the State of Oklahoma as an adult day care
				center.
(c) The provider must meet
				all applicable local, state, and federal regulations.
(d) The provider must maintain an inquiry log
				of all individuals requesting Programs of All-Inclusive Care for the Elderly
				(PACE) services. This log will be available to the OHCA at all times. The log
				must include:
(1) type of contact;
(2) date of contact;
(3) name and phone number of the individual
				requesting services;
(4) name and
				address of the potential participant; and
(5) date of enrollment, or reason for denial
				if the individual is not enrolled.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 18 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 317:35-18-5 - Eligibility criteria

Current through Vol. 41, No. 20, July 1, 2024
(a) To be eligible
				for participation in Programs of All-Inclusive Care for the Elderly (PACE), the
				applicant must:
(1) Be age fifty-five (55)
				years or older;
(2) Live in a PACE
				service area;
(3) Be determined by
				the state to meet nursing facility level of care; and
(4) Be determined by the PACE
				interdisciplinary team (IDT) as able to be safely served in the community at
				the time of enrollment. If the PACE provider denies enrollment because the IDT
				determines that the applicant cannot be served safely in the community, the
				PACE provider must:
(A) Notify the applicant
				in writing of the reason for the denial;
(B) Refer the applicant to alternative
				services as appropriate;
(C)
				Maintain supporting documentation for the denial and notify the Centers for
				Medicare and Medicaid Services and the Oklahoma Health Care Authority (OHCA) of
				the denial and submit that documentation to the OHCA for review; and
(D) Advise the applicant orally and in
				writing of the grievance and appeals process.