Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 85 - ADVANTAGE PROGRAM WAIVER SERVICES › Section 317:30-5-764 - Reimbursement

Current through Vol. 41, No. 20, July 1, 2024
(a) Rates for
				  Waiver services are set in accordance with the rate-setting process by the
				  State Plan Amendment and Rate Committee (SPARC) and approved by the Oklahoma
				  Health Care Authority(OHCA) Board.
(1) The
				  rate for Nursing Facility (NF) respite is set equivalent to the rate for
				  routine level of care NF services that require providers having equivalent
				  qualifications;
(2) The rate for
				  daily units for Adult Day Health is set equivalent to the rate established by
				  the Oklahoma Department of Human Services (OKDHS) for equivalent services
				  provided for the OKDHS Adult Day Service Program that requires providers have
				  equivalent qualifications.
(3) The
				  rate for units of home-delivered meals is set equivalent to the rate
				  established by the OKDHS for the equivalent services provided for the OKDHS
				  Home-Delivered Meals Program that require providers having equivalent
				  qualifications.
(4) The rates for
				  units of ADvantage Personal Care and In-Home Respite are set equivalent to
				  State Plan Agency Personal Care unit rate that requires providers have
				  equivalent qualifications.
(5) The
				  rates for Advanced Supportive/Restorative Assistance is set equivalent to 1.077
				  of the State Plan Agency Personal Care unit rate;
(6) Consumer-Directed Personal Assistance
				  Services and Supports (CD-PASS) rates are determined using the Individual
				  Budget Allocation (IBA) Expenditure Accounts Determination process for each
				  member. The IBA Expenditure Accounts Determination process includes
				  consideration and decisions about the items listed in (A) B (C) of this
				  paragraph.
(A) The IBA Expenditure Accounts
				  Determination constrains total Medicaid reimbursement for CD-PASS services to
				  be less than expenditures for equivalent services using agency providers.
(B) The Personal Care (PSA) and
				  Personal Care Advanced Supportive/Restorative (APSA) service unit rates are
				  calculated by the OKDHS Aging Services (AS) during the CD-PASS service
				  eligibility determination process. OKDHS AS sets the PSA and APSA unit rates at
				  a level that is not less than eighty percent(80%) and not more than ninety-five
				  percent(95%) of the comparable PSA or APSA service rates. The allocation of
				  portions of the PSA and/or APSA rates to cover salary, mandatory taxes, and
				  optional benefits including Worker's Compensation insurance, when available, is
				  determined individually for each member using the CD-PASS IBA Expenditure
				  Accounts Determination Process.
(C)
				  The IBA Expenditure Accounts Determination process defines the level of program
				  financial resources required to meet the member's need for CD-PASS services.
				  When the member's need for services changes due to a change in
				  health/disability status or a change in the level of support available from
				  other sources to meet needs, the case manager, based upon an updated
				  assessment, amends the person-centered service plan to increase CD-PASS service
				  units appropriate to meet additional member need. OKDHS AS, upon favorable
				  review, authorizes the amended person-centered service plan and updates the
				  member's IBA. Service amendments based on changes in member need for services
				  do not change an existing PSA or APSA rate. The member with assistance from the
				  Financial Management Service, reviews and revises the IBA Expenditure Accounts
				  calculation annually or more often to the extent appropriate and
				  necessary.
(7) Three (3)
				  per diem reimbursement rate levels for the ADvantage assisted living services
				  are set. Different rate per diem levels are established to adequately reimburse
				  the provider for the provision of different levels of service to accommodate
				  different level of member need for services-type, intensity and frequency to
				  address member Activities of Daily Living and Instrumental Activities of Daily
				  Living (ADL/IADL) and health care needs. Rounded to the nearest cent, the
				  lowest level Assisted Living Services per diem rate is set equivalent to 11.636
				  times the State Plan Agency Personal Care unit rate; the mid-level per diem
				  rate is set equivalent to 15.702 times the State Plan Agency Personal Care unit
				  rate; and the highest level Assisted Living Services per diem rate is set
				  equivalent to 21.964 times the State Plan Agency Personal Care unit rate. The
				  specific rate level appropriate to a particular member's service is determined
				  by Uniform Comprehensive Assessment Tool, Part III (UCAT III) assessment by the
				  member's Advantage case manager employed by a case management agency
				  independent of the Assisted Living Services provider. ADvantage payment is not
				  made for twenty-four (24) hour skilled care in an assisted living center.
				  Federal financial participation is not available for room and board, items of
				  comfort or convenience, or the costs of facility maintenance, upkeep and
				  improvement. Separate payment is not made for ADvantage services of personal
				  care, advanced supportive/restorative assistance, skilled nursing, Personal
				  Emergency Response System, home-delivered meals, adult day health or
				  environmental modifications to a member while receiving assisted living
				  services since these services are integral to and inherent in the provision of
				  assisted living service. However, separate payment may be made for Medicaid
				  State Plan and/or Medicare Home Health benefits to members receiving ADvantage
				  assisted living. Separate payment is not made for ADvantage respite to a member
				  while receiving assisted living services since by definition assisted living
				  services assume the responsibility for twenty-four (24) hour
				  oversight/monitoring of the member, eliminating the need for informal support
				  respite. The member is responsible for room and board costs; however, for an
				  ADvantage member, the ADvantage assisted living services provider is allowed to
				  charge a maximum for room and board that is no more than ninety (90) percent of
				  the Supplemental Security Income (SSI) Federal Benefit Rate. When, per Oklahoma
				  Administrative Code (OAC)
				  317:35-17-1(b)
				  and
				  317:35-17-11,
				  the member has a vendor payment obligation, the provider is responsible for
				  collecting the vendor payment from the member.
(8) The maximum total annual reimbursement
				  for a member's hospice care within a twelve (12) month period is limited to an
				  amount equivalent to eighty-five (85) percent of the Medicare Hospice Cap
				  payment.