Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-2 - Nursing Facility (NF) program medical eligibility determination

Current through Vol. 41, No. 20, July 1, 2024
The Oklahoma Department of Human Services (DHS) area nurse
				  or nurse designee, determines medical eligibility for NF services based on the
				  DHS nurse's Uniform Comprehensive Assessment Tool (UCAT) Part III assessment of
				  the client's needed level of care, the outcome of the Level II Preadmission
				  Screening and Resident Review (PASRR), when completed, and his or her
				  professional judgment. The Oklahoma Health Care Authority (OHCA) Level of Care
				  Evaluation Unit(LOCEU) makes some determinations when the PASRR is involved.
				  Refer to Oklahoma Administrative Code (OAC)
				  317:35-19-7.1(3)
				  for NF level of care medical eligibility requirements.
(1) When NF care services are requested prior
				to admission, the same rules related to medical eligibility determination
				identified in OAC
				317:35-17-5 for ADvantage
				services are followed.
(2) The DHS
				nurse reviews the PASRR Level I in the OHCA system; completes the UCAT III; and
				enters the date OHCA received the PASRR Level I (LTC-300R) from the NF and
				admission date to the NF; medical eligibility effective date and notes any
				Level II PASRR results if available in the UCAT Part III. This information is
				submitted to the DHS area nurse for medical eligibility
				determination.
(3) PASRR
				requirements are identified in OAC
				317:35-19-8 and
				317:35-19-9.
(4) When it is not possible for the UCAT Part
				III assessment to be completed prior to admission, the NF is responsible for
				notifying the DHS of the admission. Notification is mailed or faxed on DHS Form
				08MA083E, Notification Regarding Patient In A Nursing Facility, Intermediate
				Care Facility for the Intellectually Disabled or Hospice, and Management
				Recipient Funds to the local DHS county office. Upon receipt, the DHS county
				office processes Forms 08MA083E and 08MA084E and completes and forwards the
				Form 08MA038E, Notice Regarding Financial Eligibility to the NF. Identified
				sections of the UCAT Part III reflecting the domains for meeting medical
				criteria are completed for applicants residing in the NF at the time of
				assessment. The area nurse or nurse designee, confirms the date of medical
				eligibility and records it in the system. The facility is responsible for
				performing the PASRR Level I screen and consulting with OHCA staff to determine
				when a need exists for a Level II screen. The DHS nurse completes the
				assessment within fifteen-business (15-business) days of PASRR clearance when
				the individual's needs are included in an active DHS coded case. When the
				individual's needs are not included in an active case, the assessment is
				completed within twenty-business (20-business) days of PASRR
				clearance.
(5) The area nurse or
				nurse designee, evaluates the PASRR Level I screen and the UCAT Part III in
				consultation with the DHS nurse when the completed LTC-300R and/or facility
				documentation shows a need exists for a possible Level II screen. The area
				nurse or nurse designee consults with OHCA staff as necessary.
(6) The area nurse or nurse designee,
				evaluates the UCAT Parts I and III, to determine if the applicant meets the
				medical eligibility criteria for NF level of care. Individuals may be
				medically-certified for NF level of care for various lengths of time depending
				on the client's needs. The area nurse or nurse designee, enters the medical
				eligibility decision and, when required, the medical certification review date
				into Aging Services Division Electronic Data Entry and Retrieval System
				(ELDERS) within ten-business (10-business) days. A medical eligibility
				redetermination is not required when a client is discharged from the NF for a
				period not to exceed ninety-calendar (90-calendar) days and the original
				certification is current.
(7) When
				the DHS nurse recommends NF level of care and the client is determined by the
				area nurse or nurse designee, not to be medically eligible for NF level of
				care, the DHS nurse can submit additional information to the area nurse or
				nurse designee. When necessary, a visit by the DHS nurse to obtain additional
				information is initiated at the recommendation of the area nurse or nurse
				designee.
(8) Categorical
				relationship must be established for determination of eligibility for NF
				services. When categorical relationship to disability has not been established,
				the worker submits the same information, per OAC
				317:35-5-4(2) to
				the LOCEU to request a determination of eligibility for categorical
				relationship. LOCEU renders a decision on categorical relationship to the
				disabled applicant using the Social Security Administration (SSA) definition. A
				follow-up with the SSA by the DHS worker is required to ensure the SSA
				disability decision agrees with the LOCEU decision.
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 5-28-98 (emergency); Amended at 16
				  Ok Reg 1438, eff 5-27-99; Amended at 17 Ok Reg 2410, eff 6-26-00; Amended at 20
				  Ok Reg 1958, eff 6-26-03; Amended at 21 Ok Reg 2252, eff
				  6-25-04