Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 50 - Home and Community-Based Waiver Services › Subchapter 1 - Medically Fragile Waiver Services › Section 317:50-1-14 - Description of services

Current through Vol. 41, No. 20, July 1, 2024
Services included in the Medically Fragile waiver program
				  are as follows:
(1)
Case
				Management.
(A) Case management
				services are services that assist a member in gaining access to medical,
				social, educational or other services, regardless of payment source of
				services, that may benefit the member in maintaining health and safety. Case
				managers initiate and oversee necessary assessments and reassessments to
				establish or reestablish waiver program eligibility. Case managers develop the
				member's comprehensive service plan, listing only services which are necessary
				to prevent institutionalization of the member, as determined through
				assessments. Case managers initiate the addition of necessary services or
				deletion of unnecessary services, as dictated by the member's condition and
				available support. Case managers monitor the member's condition to ensure
				delivery and appropriateness of services and initiate service plan reviews. If
				a member requires hospital or skilled nursing facility(NF) services, the case
				manager assists the member in accessing institutional care and, as appropriate,
				periodically monitors the member's progress during the institutional stay and
				helps the member transition from institution to home by updating the service
				plan and preparing services to start on the date the member is discharged from
				the institution. Case managers must meet Medically Fragile waiver program
				minimum requirements for qualification and training prior to providing services
				to members. Prior to providing services to members choosing to self-direct
				their services, case managers are required to receive training and demonstrate
				knowledge regarding the self-directed service delivery model.
(B) Providers may only claim time for
				billable case management activities described as follows:
(i) A billable case management activity is
				any task or function defined under Oklahoma Administrative Code (OAC)
				317:50-1-15(1)(A),
				that only a Medically Fragile case manager because of skill, training, or
				authority, can perform on behalf of a member;
(ii) Ancillary activities such as clerical
				tasks like mailing, copying, filing, faxing, drive time, or
				supervisory/administrative activities are not billable case management
				activities, although the administrative cost of these activities and other
				normal and customary business overhead costs have been included in the
				reimbursement rate for billable activities. Payment is not allowed for written
				reports or record documentation.
(C) Case management services are prior
				authorized and billed per fifteen (15) minute unit of service using the rate
				associated with the location of residence of the member served.
(i) Case Management services are billed using
				a standard rate for reimbursement for billable service activities provided to a
				member who resides in a county with population density greater than twenty-five
				(25) persons per square mile.
(ii)
				Case management services are billed using a very rural/outside providers'
				service rate for billable service activities provided to a member who resides
				in a county with population density equal to or less than twenty-five (25)
				persons per square mile. An exception would be services to members that reside
				in OHCA-identified zip codes in Osage county adjacent to metropolitan areas of
				Tulsa and Washington counties. Services to these members are prior authorized
				and billed using the standard rate.
(iii) The latest United States Census,
				Oklahoma Counties population data is the source for determination of whether a
				member resides in a county with a population density equal to or less than
				twenty-five (25) persons per square mile, or resides in a county with a
				population density greater than twenty-five (25) persons per square mile.
(D) Case managers
				providing case management services to Medically Fragile waiver members must
				submit monthly monitoring case notes on a monthly basis to the OHCA Medically
				Fragile waiver staff.
(E) Providers
				of Home and Community-Based waiver services (HCBS) for the member, or those who
				have an interest in or are employed by a provider of HCBS for the member, must
				not provide case management or develop the person-centered service plan, except
				when the State demonstrates that the only willing and qualified entity to
				provide case management and/or develop person-centered service plans in a
				geographic area also provides HCBS.