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 317:35-15-10 - Medical eligibility redetermination for State Plan Personal Care (SPPC) services

Current through Vol. 41, No. 20, July 1, 2024
(a)
Medical eligibility redetermination.
The Oklahoma Human Services
				(OKDHS) Health Care Management Nurse (HCMN) III completes a medical
				redetermination before the end of the long-term care medical certification
				period.
(b)
Recertification.
The OKDHS HCMN I or II re-assesses the SPPC
				service members eighteen (18) years of age and older, for medical
				re-certification based on the member's needs and level of caregiver support
				required, using the Uniform Comprehensive Assessment Tool (UCAT) at least every
				thirty-six (36) months. Members younger than eighteen (18) years of age, are
				re-evaluated by the OKDHS HCMN I or II using the UCAT on a twelve (12) month
				basis or sooner when needed. During this re-certification assessment, the OKDHS
				HCMN I or II informs the member of the state's other SoonerCare (Medicaid)
				long-term care options. The OKDHS HCMN I or II submits the re-assessment to the
				OKDHS HCMN III for recertification. Documentation is sent to the OKDHS area
				nurse no later than the tenth (10 th) calendar day of the month certification
				expires. When the OKDHS HCMN III determines medical eligibility for SPPC
				services, a recertification review date is entered on the system.
(c)
Change in amount of units or
				tasks.
When the SPPC provider agency determines a need for a change in
				the amount of units or tasks in the service, a care plan is completed and
				submitted to OKDHS within five (5) business days of identifying the assessed
				need. TheOKDHS HCMN III approves or denies the change prior to
				implementation.
(d)
SPPC
				services voluntary closure.
When a SPPC member decides personal care
				services are no longer needed to meet his or her needs, a medical decision is
				not needed. The member is sent a Voluntary Withdrawal Requestfor confirmation
				and signature, and the request is entered into the electronic system upon
				receipt. A closure notificationis submitted to the provider agencyvia the
				electronic system.
(e)
Resuming personal care services.
When aSPPC member approved for
				SPPC services is without services for less than ninety (90) calendar days, but
				the member has current medical and SoonerCare (Medicaid) financial eligibility
				approval, SPPC services may be resumed using the member's previously approved
				plan. The personal care provider agency nurse contacts the member to determine
				when changes in health or service needs occurred. When changes are identified,
				the provider agency nurse completes an assessment visit and submits a SPPC
				services skilled nursingneed re-assessment within ten (10) business days of the
				resumed plan start date. When the member's needs dictate, the personal care
				provider agency may submit a request for a change in authorized SPPC service
				units. When no changes occur, the agency nurse documents the contact in the
				electronic system for the OKDHS HCMN I or II ten (10) business days of the
				resumed plan start date.
(f)
Financial ineligibility.
When the OKDHS social services specialist
				(SSS) determines a member does not meet SoonerCare(Medicaid) financial
				eligibility criteria, the OKDHS HCMN III is notified to initiate the closure
				process due to financial ineligibility. When OKDHS determines a member to be
				financially ineligible for SPPC services, they notify the member of the
				determination, and his or her right to appeal the decision in writing. A
				closure notificationis submitted to the provider agency.
(g)
Closure due to medical
				ineligibility.
When OKDHS determines to be medically ineligible for SPPC
				services, they notify the member of the determination, and his or her right to
				appeal the decision, in writing. When medical eligibility redetermination is
				not made prior to current medical eligibility expiration, the existing medical
				eligibility certification is automatically extended until care level
				redetermination is established. For members:
(1) Who are not hospitalized or in an
				extended medical care facility, the existing medical eligibility certification
				is extended for a maximum sixty (60) calendar days from the date of the
				previous medical eligibility expiration date;
(2) Who are hospitalized or in an extended
				medical care facility, the existing medical eligibility certification is
				extended for thirty (30) calendar days from the date of discharge from the
				facility or for sixty (60) calendar days from the date of previous medical
				eligibility expiration date, whichever is longer;
(3) Whose medical eligibility redetermination
				is not made by applicable extended deadline, the member is determined to be
				medically ineligible; or
(4) Who no
				longer meet medical eligibility or cannot be located to complete the
				redetermination assessment, the HCMN I or II notifies the HCMN III. The HCMN
				III updates the system's medical eligibility end date and notifies the HCMN I
				or II of effective end date. A closure notificationis submitted to the provider
				agency.