reglab/statecodes huggingface dataset:
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 5 - Member Services › Part 11 - OTHER COMMUNITY RESIDENTIAL SUPPORTS › Section 317:40-5-153 - Daily Living Supports for the Homeward Bound Waiver

Current through Vol. 41, No. 20, July 1, 2024
(a)
Introduction.
Daily Living
				  Supports are provided by an agency with a valid Oklahoma Health Care Authority
				  (OHCA) contract.
(1) Daily Living Supports
				  require meeting the daily support needs of the member living in the home.
(A) In accordance with the needs of the class
				  member, Daily Living Supports include hands-on assistance, supervision, or
				  prompting so that the member performs the task, such as eating, bathing,
				  dressing, toileting, transferring, personal hygiene, light housework, money
				  management, community safety, recreation, social, health, or medication
				  management.
(B) Daily Living
				  Supports are provided by staff that do not live in the home and include
				  assistance with cognitive tasks or provision of services to prevent a member
				  from harming self or others, in accordance with the needs of the
				  member.
(C) Daily Living Supports
				  also include:
(i) the provision of staff
				  training per OAC
				  340:100-3-30
				  to meet the specific needs of the member;
(ii) program supervision that includes
				  24-hour availability of response staff to meet schedules and unpredictable
				  needs;
(iii) program
				  oversight;
(iv) assisting the
				  member in obtaining services and supplies;
(v) developing and assuring emergency plans
				  are in place;
(vi) coordinating
				  overall safety and supports in the home; and
(vii) assisting members with personal money
				  management.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 5 - Member Services › Part 11 - OTHER COMMUNITY RESIDENTIAL SUPPORTS › Section 317:40-5-154 - Intensive Personal Supports in the Homeward Bound Waiver

Current through Vol. 41, No. 20, July 1, 2024
(a)
Introduction.
Intensive
				  Personal Supports are support services provided to class members who need an
				  enhanced level of direct support in order to successfully reside in a community
				  based setting. Intensive Personal Supports build upon the level of support
				  provided by a Habilitation Training Specialist or Daily Living Supports staff
				  by utilizing a second staff person on duty to provide assistance and training
				  in self-care, daily living, recreational, and habilitation
				  activities.
(b)
Eligibility.
Intensive Personal Supports are provided by OHCA
				  contracted provider agencies to class members who:
(1) are eighteen years of age or older,
				  unless approved by the Director of OKDHS or designee; and
(2) require a second support staff in order
				  to meet their needs, when there is no other resolution.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-1 - Overview of Waiver Employment Services

Current through Vol. 41, No. 20, July 1, 2024
(a) There are many employment service options
				available. The options given in (1) through (4) of this subsection are not a
				continuum, but are prioritized as most desirable by people with and without
				disabilities. Provider agencies assess each service recipient in maximizing
				employment options.
(1) The optimum goal is
				full-time employment at prevailing wage in business or industry at an
				occupation of the service recipient's choice with natural supports. If
				prevailing wage is not available, then employment is at minimum wage with or
				without paid supports.
(2) If a
				service recipient cannot secure enough work hours through a single job of the
				service recipient's choice, then two part-time jobs or a job that is not the
				service recipient's first preference may need to be sought to equal a full time
				job.
(3) If a fully integrated
				placement is not currently available, employment of the service recipient's
				choice in an enclave in a business or industry, with or without paid supports,
				is an option.
(4) If there are no
				paid jobs to be found, temporary unpaid training or volunteer service in
				accordance with Department of Labor regulations, with or without paid supports,
				may be an option for the purpose of resume building or job exploration, or
				temporary participation in real work in a center-based setting can be
				obtained.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-3 - Eligibility for Waiver Employment Services

Current through Vol. 41, No. 20, July 1, 2024
(a) Individuals served through Waiver
				Employment Services must be:
(1) 16 years of
				age and older for persons receiving services through the Community Waiver, In
				Home Supports Waiver, or the Homeward Bound Waiver; and
(2) approved for waiver services, per
				Oklahoma Administrative Code (OAC)
				317:40-1-1.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-4 - Services provided through Waiver Employment Services

Current through Vol. 41, No. 20, July 1, 2024
(a) Waiver Employment Services are offered
				under the Home and Community-Based Waiver for persons with intellectual
				disabilities at rates prescribed by the Oklahoma Health Care
				Authority.
(b) Waiver Employment
				Services include:
(1) Vocational Habilitation
				Training Specialist, Supplemental Support;
(2) Employment Training Specialist
				;
(3) Center-Based
				Services;
(4) Community-Based
				Services;
(5) Enhanced
				Community-Based Services;
(6) Job
				Coaching;
(7) Enhanced Job
				Coaching; and
(8) Stabilization
				Services.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-5 - Community-based services

Current through Vol. 41, No. 20, July 1, 2024
Community-based services are provided in sites and at times
				  typically used by others in the community and promote independence,
				  communityinclusion, and the creation of natural supports. Community-based
				  services must reflect the member's choice and values intypical age and cultural
				  situations.
(1) Approved
				community-based services are individualized work-related supports targeting
				inclusion into integrated experiences and are pre-planned, documented
				activities supported by a schedule relating to the member's identified
				employment outcomes. Approved community-based services activities include:
(A) active participation in formalized
				volunteer activities;
(B) active
				participation in paid or unpaid work experience sites in community
				settings;
(C) training through
				generic entities such as trade schools, technology centers, community colleges,
				or other community groups. The provider is paid for the time when direct
				supports are necessary and provided;
(D) stamina-enhancing programs in integrated
				settings;
(E) transportation to and
				from employment or community-based activities;
(F) meals and breaks during the member's
				employment activities that occur in the community at a location used for the
				same purpose, with others without disabilities;
(G) job tours or job shadowing scheduled with
				and provided by a community-business entity;
(H) using Workforce OK services;
				and
(I) attending job fairs.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-6 - Center-based services

Current through Vol. 41, No. 20, July 1, 2024
(a) Center-based
				services are employment services provided where the majority of the people at
				the site have disabilities. These settings facilitate opportunities to seek
				employment in competitive settings and support access to the greater community.
(b) Center-based services are
				pre-planned, documented activities that relate to the member's identified
				employment outcomes.
(c) Examples
				of center-based services are active participation in:
(1) learning and work experiences where the
				individual can develop general, non-job-task specific strengths and skills that
				contribute to employability in paid employment in integrated community
				settings;
(2) team-prescribed
				therapy programs, such as speech, physical therapy, or a switch activation
				program implemented by employment provider staff in the workshop or other
				center-based setting;
(3) computer
				classes, General Education Development preparation, job club, interviewing
				skills, or other classes where all participants have disabilities, even when
				the location is in the community; and
(4) mealtimes where the majority of people
				with disabilities are employed.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-7 - Job coaching services

Current through Vol. 41, No. 20, July 1, 2024
(a)
				Job coaching services:
(1) Are pre-planned,
				documented activities related to the member's identified employment outcomes
				that include training at the work site and support by provider agency staff who
				have completed Developmental Disabilities Services (DDS) sanctioned training,
				per Oklahoma Administrative Code (OAC)
				340:100-3-38.2;
(2) Promote the member's capacity
				to secure and maintain integrated employment at a job of the member's choice
				paying at or more than minimum wage, or working to achieve minimum wage;
(3) Provide active participation
				in paid work. Efforts are made in cooperation with employers to adapt normal
				work environments to fit the needs of members through the maintenance of an
				active relationship with the business;
(4) Are available for individual and group
				placements.
(A) Individual placement is:
(i) One (1) member receiving job coaching
				services who:
(I) Works in an integrated job
				setting;
(II) Is paid at or more
				than minimum wage;
(III) Does not
				receive services from a job coach who is simultaneously responsible for
				continuous job coaching for a group;
(IV) Is employed by a community employer or
				provider agency; and
(V) Has a job
				description that is specific to the member's work.
(ii) Authorized when on-site supports by a
				certified job coach are provided more than twenty percent (20%) of the member's
				compensable work time. Job coaching services rate continues until a member
				reaches twenty percent (20%) or less job coach intervention for four(4)
				consecutive weeks, at which time stabilization services beginand;
(iii) Authorized through remote supports per
				Health Insurance Portability and Accountability Act (HIPAA) compliant
				technology, when the Personal Support Team (Team) has an approved remote
				supports risk assessment.
(B) Small group placement is:
(i) Two (2) to three (3) members receiving
				continuous support in an integrated work site who are paid at, or more than,
				minimum wage; or
(ii) Up to four
				(4) to five (5) members receiving continuous support in an integrated work
				site, who may earn less than minimum wage.
(5) Are based on the amount of time for which
				the member is compensated by the employer, except per OAC
				317:40-7-11.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-8 - Employment training specialist services

Current through Vol. 41, No. 20, July 1, 2024
Employment training specialist (ETS) services include
				  evaluation, training, and supportive assistance that allow the member to obtain
				  and engage in remunerative employment. ETS services are:
(1) provided by a certified job
				coach;
(2) not available when
				subcontracting;
(3) used to help a
				member with a new job in a generic employment setting.
(A) ETS services are:
(i) not available if the member held the same
				job for the same employer in the past;
(ii) available when the member requires 100%
				on-site intervention for up to the number of hours the member works per week
				for six weeks per Plan of Care year; and
(iii) used in training members employed in
				individual placements on new jobs when the:
(I) member receives at least minimum wage;
				and
(II) employer is not the
				employment services provider.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-9 - Intensive Training Services [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 15 Ok Reg 3873,
				  eff 7-1-98 (emergency); Added at 16 Ok Reg 1445, eff 5-27-99; Revoked at 18 Ok
				  Reg 2985, eff 5-17-01 (emergency); Revoked at 19 Ok Reg 1090, eff
				  5-13-02
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-10 - Assessment [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 15 Ok Reg 3873,
				  eff 7-1-98 (emergency); Added at 16 Ok Reg 1445, eff 5-27-99; Revoked at 18 Ok
				  Reg 2985, eff 5-17-01 (emergency); Revoked at 19 Ok Reg 1090, eff
				  5-13-02
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-11 - Stabilization Services

Current through Vol. 41, No. 20, July 1, 2024
Stabilization Services are ongoing support services needed
				  to maintain a member in an integrated competitive employment site.
				  Stabilization Services are provided for up to two(2) years per job.
				  Stabilization Services continue until the next Plan of Care following the end
				  of two (2) years of Stabilization Services.
(1) Stabilization Services are provided when
				the job coach intervention time required at the job site is twenty percent
				(20%) or less of the member's total work hours for four (4) consecutive weeks
				or when the member moved from Department of Rehabilitation Services (DRS)
				services.
(A) If, after the member moves to
				StabilizationServices the Team determines that support is needed above twenty
				percent (20%) for longer than two(2) weeks, the Team may revise the member's
				Plan of Care to reflect the need for Job Coaching Services.
(B) A member receiving services from DRS
				moves to services funded by DDS upon completion of the Job Stabilization
				milestone. The employment provider agency submits the request for transfer of
				funding during the Job Stabilization milestone as described in the DRS
				Supported Employment contract.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-12 - Enhanced rates

Current through Vol. 41, No. 20, July 1, 2024
An enhanced rate is available for both community-based group
				  services and group job-coaching services when necessary to meet a member's
				  intensive personal needs in the employment setting(s). The need for the
				  enhanced rate is identified through the Personal Support Team process and is
				  supported by documentation in the Individual Plan (Plan) with consideration of
				  risk assessment per Oklahoma Administrative Code(OAC)
				  340:100-5-56 and
				  assessment of medical, nutritional, mobility needs , and the:
(1) Team assessment of the member's needs per
				OAC
				340:100-5-51,
				OAC
				340:100-5-56, OAC
				340:100-5-57,
				and OAC
				340:100-5-26;
(2) member must:
(A) have a protective intervention protocol
				(PIP) that:
(i) contains a restrictive or
				intrusive procedure per OAC
				340:100-1-2
				implemented in the employment setting; and
(ii) is approved by the State Behavior Review
				Committee (SHRBRC) per OAC
				340:100-3-14
				or by the Developmental Disabilities Services (DDS) staff per OAC
				340:100-5-57;
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-13 - Supplemental supports for center-based services

Current through Vol. 41, No. 20, July 1, 2024
(a) When a member receiving center-based
				services needs additional supports, the provider assigns staff in patterns that
				most effectively meet the needs of each member as indicated by a personal care
				and/or a risk assessment and defined in the Individual Plan (IP) or Protective
				Intervention Protocol (PIP).
(b)
				When re-arranging staff patterns is not sufficient to meet the member's needs,
				the provider may file a request and plan for Supplemental Supports utilizing
				Vocational Habilitation Training Specialist Services. Supplemental supports are
				claimed only when provided by a staff member who completed all specialized
				training and individual-specific training prescribed by the Team per Oklahoma
				Administrative Code(OAC)
				340:100-3-38.
(c) Supplemental supports for
				center-based services include two types of services, behavioral continuous
				support, and personal care intermittent support.
(1)
Continuous supplemental
				supports.
Continuous supplemental supports cannot exceed 15 hours per
				week for persons receiving services through the Homeward Bound Waiver unless
				specifically approved through the exception process per OAC
				317:40-7-21.
(A) To be eligible for continuous
				supplemental supports, the member must have:
(i) a behavioral PIP that:
(I) contains a restrictive or intrusive
				procedure per OAC
				340:100-1-2
				implemented in the employment setting;
(II) is approved by the State Human Rights
				and Behavior Review Committee (SHRBRC) per OAC
				340:100-3-14
				or by the Developmental Disabilities Services (DDS) staff per OAC
				340:100-5-57;
				or
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-14 - Transportation for Waiver Vocational Services [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 15 Ok Reg 3873,
				  eff 7-1-98 (emergency); Added at 16 Ok Reg 1445, eff 5-27-99; Revoked at 18 Ok
				  Reg 2985, eff 5-17-01 (emergency); Revoked at 19 Ok Reg 1090, eff
				  5-13-02
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-15 - Service requirements for employment services through Home and Community-Based Services (HCBS) Waivers

Current through Vol. 41, No. 20, July 1, 2024
(a)
				The Oklahoma Human Services (OKDHS) Developmental Disabilities Services (DDS)
				case manager, the member, the member's family or, when applicable, the member's
				legal guardian, and the member's provider develop a preliminary plan of
				services including the:
(1) Site and amount
				of the services offered;
(2) Types
				of services to be delivered; and
(3) Expected outcomes.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-16 - Completion of the Employment Services Plan (ESP) [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 15 Ok Reg 3873,
				  eff 7-1-98 (emergency); Added at 16 Ok Reg 1445, eff 5-27-99; Revoked at 18 Ok
				  Reg 2985, eff 5-17-01 (emergency); Revoked at 19 Ok Reg 1090, eff
				  5-13-02
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-17 - Subcontracting with a secondary vocational service provider [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 15 Ok Reg 3873,
				  eff 7-1-98 (emergency); Added at 16 Ok Reg 1445, eff 5-27-99; Revoked at 18 Ok
				  Reg 2985, eff 5-17-01 (emergency); Revoked at 19 Ok Reg 1090, eff
				  5-13-02
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-18 - Contracts with industry

Current through Vol. 41, No. 20, July 1, 2024
(a)
				The Oklahoma Department of Human Services (OKDHS) Developmental Disabilities
				Services Division (DDSD) may contract with an industry to provide job coaching
				services through a Natural Supports Initiative. The employer:
(1) designates an existing employee to serve
				as job coach.
(A) The job coach completes
				training as approved by the DDSD director of Human Resource
				Development.
(B) Training and
				support are available for members on the job; and
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-19 - Changing Waiver Employment Services providers [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 15 Ok Reg 3873,
				  eff 7-1-98 (emergency); Added at 16 Ok Reg 1445, eff 5-27-99; Amended at 18 Ok
				  Reg 2985, eff 5-17-01 (emergency); Amended at 19 Ok Reg 1090, eff 5-13-02;
				  Revoked at 22 Ok Reg 2531, eff 7-11-05
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-20 - Waiver Employment Services provider staff qualifications and training

Current through Vol. 41, No. 20, July 1, 2024
(a) The provider
				designates a program manager to supply work-site supervision, guidance, and
				oversight of job coach specialists and paraprofessional staff providing direct
				services in the waiver employment program. Prior to assuming program management
				duties, the program manager:
(1) has
				completed all required training specified in OAC
				340:100-3-38;
				and
(2) has a minimum of four years
				of any combination of college level education and "full time equivalent"
				experience in serving persons with disabilities.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-21 - Exception process for employment services through Home and Community-Based Services Waivers

Current through Vol. 41, No. 20, July 1, 2024
(a) All exceptions
				to rules in Oklahoma Administrative Code (OAC) 317:40-7 are:
(1) approved, per OAC 317:40-7-21 prior to
				service implementation;
(2)
				intended to result in the personal support team (Team) development of an
				employment plan tailored to meet the member's needs;
(3) identified in the Individual Plan (Plan)
				process, per OAC
				340:100-5-50 through
				340:100-5-58; and
(4) documented and recorded in the Individual
				Plan by the Developmental Disabilities Services Division (DDS) case manager
				after Team approval.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 7 - Employment Services Through Home and Community-Based Services Waiver › Section 317:40-7-22 - Value-Based Payments (VBP)

Current through Vol. 41, No. 20, July 1, 2024
(a)
Purpose.
Oklahoma Human Services (OKDHS) Developmental
				Disabilities Services (DDS) provides incentive payments to support a member as
				he or she moves toward competitive integrated employment. VBPs are intended to
				further opportunities for Oklahomans with disabilities to live independently
				and work in competitive integrated employment. VBPs are included in the
				member's Individual Plan (Plan) and arrangements for this service are made
				through the DDS case manager. VBPs support members eighteen (18) years of age
				and older who receive employment services through the:
(1) In-Home Supports Waiver;
(2) Homeward Bound Waiver; or
(3) Community Waiver.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 40 - Developmental Disabilities Services › Subchapter 9 - Self-Directed Services › Section 317:40-9-1 - Self-directed services (SDS)

Current through Vol. 41, No. 20, July 1, 2024
(a)
Applicability.
This Section applies to SDS provided through Home
				and Community-Based Services (HCBS) Waivers operated by the Oklahoma Human
				Services (OKDHS) Developmental Disabilities Services (DDS).
(b)
Member option.
Traditional
				service delivery methods are available for eligible members who do not elect to
				self-direct services.
(c)
General information.
SDS are an option for members receiving HCBS
				through the In-Home Supports Waiver for Adults, In-Home Supports Waiver for
				Children, and the Community Waiver when the member lives in a non-residential
				setting. SDS provides members the opportunity to exercise choice and control in
				identifying, accessing, and managing specific Waiver services and supports in
				accordance with his or her needs and personal preferences. SDS are Waiver
				services OKDHS DDS specifies may be directed by the member or representative
				using employer and budget authority.
(1) SDS
				may be directed by:
(A) An adult member, when
				the member has the ability to self-direct;
(B) A member's legal representative including
				a parent, spouse or legal guardian; or
(C) A non-legal representative who the member
				or legal representative freely chooses.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 1 - General Provisions › Section 317:45-1-1 - Purpose and general program provisions

Current through Vol. 41, No. 20, July 1, 2024
The purpose of this Chapter is to provide rules, in
				  compliance with all applicable federal and state regulations, for the Insure
				  Oklahoma program that establishes access to affordable health coverage for
				  low-income working adults their dependents, and their spouses; foster parents;
				  and qualified college students.
Added at 23 Ok Reg 278,
				  eff 10-3-05 (emergency); Added at 23 Ok Reg 1407, eff 5-25-06; Amended at 26 Ok
				  Reg 621, eff 3-1-09 (emergency); Amended at 26 Ok Reg 2165, eff 6-25-09;
				  Amended at 27 Ok Reg 2391, eff 7-1-10 (emergency); Amended at 28 Ok Reg 1574,
				  eff 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 1 - General Provisions › Section 317:45-1-4 - Reimbursement for out-of-pocket expenses

Current through Vol. 41, No. 20, July 1, 2024
(a) Out-of-pocket expenses for all approved
				and eligible members (and/or their approved and eligible dependents) will be
				limited to five (5) percent of their annual gross household income. The OHCA
				will provide reimbursement for out-of-pocket expenses in excess of the five (5)
				percent annual gross household income. An expense must be for an allowed and
				covered service by a QBP to be eligible for reimbursement. For the purpose of
				this Section, an allowed and covered service is defined as an in-network
				service covered in accordance with a QBPs benefit summary and policies. For
				instance, if a QBP has multiple in-network reimbursement percentage
				methodologies (eighty (80) percent for level 1 provider and seventy (70)
				percent for level 2 provider) the OHCA will only reimburse expenses related to
				the highest percentage network.
(b)
				For all eligible expenses as defined above in OAC 317:45-1-4(a), the member
				must submit the OHCA required form and all OHCA required documentation to
				support that the member incurred and paid the out-of-pocket expense. The OHCA
				required documentation must substantiate that the member actually incurred and
				paid the eligible out-of-pocket expense. The OHCA may request additional
				documentation at any time to support a member's request for reimbursement of
				eligible out-of-pocket expenses.
Added at 24 Ok Reg 101,
				  eff 8-2-06 (emergency); Added at 24 Ok Reg 963, eff 5-11-07; Amended at 26 Ok
				  Reg 2169, eff 6-25-09; Amended at 27 Ok Reg 2391, eff 7-1-10 (emergency);
				  Amended at 28 Ok Reg 1574, eff 6-25-11; Amended at 29 Ok Reg 1210, eff
				  6-25-12
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 3 - Insure Oklahoma Carriers › Section 317:45-3-1 - Carrier eligibility

Current through Vol. 41, No. 20, July 1, 2024
Carriers must be able to submit all required and requested
				  information and documentation to OHCA for each benefit plan to be considered
				  for qualification. Carriers must be able to supply specific claim payment
				  scenarios as requested by OHCA. Carriers must also provide the name, address,
				  telephone number, and, if available, email address of a contact individual who
				  is able to verify employer enrollment status in a qualified benefit plan.
Added at 23 Ok Reg 278,
				  eff 10-3-05 (emergency); Added at 23 Ok Reg 819, eff 2-1-06 (emergency); Added
				  at 23 Ok Reg 2590, eff 6-25-06; Amended at 26 Ok Reg 2169, eff 6-25-09; Amended
				  at 27 Ok Reg 2391, eff 7-1-10 (emergency); Amended at 28 Ok Reg 1574, eff
				  6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 3 - Insure Oklahoma Carriers › Section 317:45-3-2 - Reviews

Current through Vol. 41, No. 20, July 1, 2024
Carriers are subject to reviews related to benefit plan
				  qualifications. These reviews may be conducted periodically to determine if
				  each qualified benefit plan continues to meet all requirements as defined in
				  317:45-5-1.
Added at 23 Ok Reg 278,
				  eff 10-3-05 (emergency); Added at 23 Ok Reg 1407, eff 5-25-06; Amended at 26 Ok
				  Reg 2169, eff 6-25-09; Amended at 27 Ok Reg 2391, eff 7-1-10 (emergency);
				  Amended at 28 Ok Reg 1574, eff 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 3 - Insure Oklahoma Carriers › Section 317:45-3-3 - Carrier rate structure requirements [EXPIRED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 28 Ok Reg 274,
				  eff 11-15-10 through 7-14-11
				  (emergency)1
1This emergency action expired
				  without being superseded by a permanent action. Upon expiration of an emergency
				  action enacting a new section, the section is no longer effective. Therefore,
				  on 7-15-11 (after the 7-14-11 expiration of this emergency action), the text of
				  Section 317:45-3-3 was no longer effective. For the official text of the
				  emergency rule that was effective from 11-15-10 through 7-14-11, see 28 Ok Reg
				  274.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 5 - Insure Oklahoma Qualified Benefit Plans › Section 317:45-5-1 - Qualified Benefit Plan requirements

Current through Vol. 41, No. 20, July 1, 2024
(a) Participating
				qualified benefit plans must offer, at a minimum, benefits that include:
(1) Hospital services;
(2) Physician services;
(3) Clinical laboratory and
				radiology;
(4) Pharmacy;
(5) visits;
(6) Well baby/well child exams;
(7) Age appropriate immunizations as required
				by law; and
(8) Emergency services
				as required by law.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 5 - Insure Oklahoma Qualified Benefit Plans › Section 317:45-5-1 - Qualified Benefit Plan requirements

Current through Vol. 41, No. 20, July 1, 2024
(a) Participating
				qualified benefit plans must offer, at a minimum, benefits that include:
(1) hospital services;
(2) physician services;
(3) clinical laboratory and
				radiology;
(4) pharmacy;
(5) office visits;
(6) well baby/well child exams;
(7) age appropriate immunizations as required
				by law; and
(8) emergency services
				as required by law.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 5 - Insure Oklahoma Qualified Benefit Plans › Section 317:45-5-2 - Closure criteria for benefit plans

Current through Vol. 41, No. 20, July 1, 2024
Eligibility for the carrier's benefit plans ends when:
(1) changes are made to the design of
				the benefit plan such that it no longer meets the requirements to be considered
				a qualified benefit plan. Carriers are required to report to OHCA any changes
				in health plans potentially affecting their qualification for participation in
				the program not less than 90 days prior to the effective date of such
				change(s).
(2) the carrier no
				longer meets the definition set forth in
				317:45-1-3.
(3) the benefit plan is no longer
				an available product in the Oklahoma market.
(4) the benefit plan fails to meet or comply
				with all requirements for a qualified benefit plan as defined in
				317:45-5-1.
Added at 23 Ok Reg 278,
				  eff 10-3-05 (emergency); Added at 23 Ok Reg 1407, eff 5-25-06; Amended at 26 Ok
				  Reg 2169, eff 6-25-09; Amended at 27 Ok Reg 2391, eff 7-1-10 (emergency);
				  Amended at 28 Ok Reg 1574, eff 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 5 - Insure Oklahoma Qualified Benefit Plans › Section 317:45-5-3 - Health plan rate structure requirements [EXPIRED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 28 Ok Reg 274,
				  eff 11-15-10 through 7-14-11
				  (emergency)1
1This emergency action expired
				  without being superseded by a permanent action. Upon expiration of an emergency
				  action enacting a new section, the section is no longer effective. Therefore,
				  on 7-15-11 (after the 7-14-11 expiration of this emergency action), the text of
				  Section 317:45-5-3 was no longer effective. For the official text of the
				  emergency rule that was effective from 11-15-10 through 7-14-11, see 28 Ok Reg
				  274.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 7 - Insure Oklahoma ESI Employer Eligibility › Section 317:45-7-1 - Employer application and eligibility requirements for Insure Oklahoma ESI

Current through Vol. 41, No. 20, July 1, 2024
(a) In order for an
				employer to be eligible to participate in the Insure Oklahoma program the
				employer must:
(1) have no more than a total
				of 250 employees on its payroll if the employer is a for-profit business
				entity. Not-for-profit businesses may participate if the employer has no more
				than a total of 500 employees on its payroll. The increase in the number of
				employees from 250 to 500 will be phased in over time as determined by the
				Oklahoma Health Care Authority (OHCA). The number of employees is determined
				based on the third month employee count of the most recently filed OES-3 form
				with the Oklahoma Employment Security Commission (OESC). Employers may provide
				additional documentation confirming terminated employees that will be excluded
				from the OESC employee count. If the employer is exempt from filing an OES-3
				form or is contracted with a Professional Employer Organization in accordance
				with OHCA rules, this determination is based on appropriate supporting
				documentation to verify employee count. Employers must be in compliance with
				all OESC requirements to be eligible for the program. As requested by the OHCA,
				employers that do not file with the OESC must submit documentation that proves
				compliance with state law;
(2) have
				a business that is physically located in Oklahoma;
(3) be currently offering, or in the
				contracting stage to offer a qualified benefit plan coverage to
				employees;
(4) contribute a minimum
				twenty-five (25) percent of the eligible employee monthly benefit plan premium
				or an equivalent forty (40) percent of premiums for dependent
				children.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 7 - Insure Oklahoma ESI Employer Eligibility › Section 317:45-7-2 - Employer eligibility determination

Current through Vol. 41, No. 20, July 1, 2024
Eligibility for employers is determined using the eligibility
				  requirements listed in
				  317:45-7-1.
				  Once an employer is determined eligible for Insure Oklahoma , the eligibility
				  period begins on the first day of the month following the date of approval. The
				  eligibility period will renew automatically unless the employer's eligibility
				  has been closed (refer to
				  317:45-7-8 ). Employers
				  will be notified of their eligibility decision.
Added at 23 Ok Reg 278,
				  eff 10-3-05 (emergency); Added at 23 Ok Reg 819, eff 2-1-06 (emergency); Added
				  at 23 Ok Reg 2590, eff 6-25-06; Amended at 24 Ok Reg 101, eff 8-2-06
				  (emergency); Amended at 24 Ok Reg 700, eff 2-1-07 (emergency); Amended at 24 Ok
				  Reg 2159, eff 6-25-07; Amended at 26 Ok Reg 2169, eff 6-25-09; Amended at 27 Ok
				  Reg 2391, eff 7-1-10 (emergency); Amended at 28 Ok Reg 1574, eff
				  6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 7 - Insure Oklahoma ESI Employer Eligibility › Section 317:45-7-3 - Employer cost sharing

Current through Vol. 41, No. 20, July 1, 2024
Employers are responsible for a portion of the eligible
				  employee's monthly benefit plan premium as defined in
				  317:45-7-1.
Added at 23 Ok Reg 278,
				  eff 10-3-05 (emergency); Added at 23 Ok Reg 1407, eff 5-25-06; Amended at 26 Ok
				  Reg 2169, eff 6-25-09; Amended at 27 Ok Reg 2391, eff 7-1-10 (emergency);
				  Amended at 28 Ok Reg 1574, eff 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 7 - Insure Oklahoma ESI Employer Eligibility › Section 317:45-7-4 - Qualifying Event

Current through Vol. 41, No. 20, July 1, 2024
Employers must allow an employee to enroll or change coverage
				  following a qualifying event. The employer must submit the required form for
				  each employee experiencing the qualifying event.
Added at 23 Ok Reg 278,
				  eff 10-3-05 (emergency); Added at 23 Ok Reg 1407, eff 5-25-06; Amended at 27 Ok
				  Reg 2391, eff 7-1-10 (emergency); Amended at 28 Ok Reg 1574, eff
				  6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 7 - Insure Oklahoma ESI Employer Eligibility › Section 317:45-7-5 - Reimbursement

Current through Vol. 41, No. 20, July 1, 2024
In order to receive a premium subsidy, the employer must
				  submit all pages of the current benefit plan invoice. Due to timely filing
				  requirements, subsidy payments will not be paid on invoices older than six (6)
				  months.
Added at 23 Ok Reg 278,
				  eff 10-3-05 (emergency); Added at 23 Ok Reg 819, eff 2-1-06 (emergency); Added
				  at 23 Ok Reg 2590, eff 6-25-06; Amended at 26 Ok Reg 2169, eff 6-25-09; Amended
				  at 27 Ok Reg 2391, eff 7-1-10 (emergency); Amended at 28 Ok Reg 1574, eff
				  6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 7 - Insure Oklahoma ESI Employer Eligibility › Section 317:45-7-6 - Credits and adjustments

Current through Vol. 41, No. 20, July 1, 2024
When an overpayment occurs, the employer must immediately
				  report the erroneous payment. When such an overpayment(s) occurs, an automatic
				  recoupment is made to the employer's account against future reimbursements. If
				  the employer is not expecting future reimbursements, either by termination from
				  the program or inactivity, the employer must repay any and all overpayments
				  that are outstanding to the OHCA.
Added at 23 Ok Reg 278,
				  eff 10-3-05 (emergency); Added at 23 Ok Reg 1407, eff 5-25-06; Amended at 27 Ok
				  Reg 2391, eff 7-1-10 (emergency); Amended at 28 Ok Reg 1574, eff
				  6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 7 - Insure Oklahoma ESI Employer Eligibility › Section 317:45-7-7 - Reviews

Current through Vol. 41, No. 20, July 1, 2024
Employers are subject to reviews related to program
				  eligibility requirements found at OAC
				  317:45-7-1
				  and subsidy payments. Eligibility may be revoked at any time if inconsistencies
				  are found. Any monies paid in error are subject to recoupment.
Added at 23 Ok Reg 278,
				  eff 10-3-05 (emergency); Added at 23 Ok Reg 1407, eff 5-25-06; Amended at 27 Ok
				  Reg 2391, eff 7-1-10 (emergency); Amended at 28 Ok Reg 1574, eff
				  6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 7 - Insure Oklahoma ESI Employer Eligibility › Section 317:45-7-8 - Closure

Current through Vol. 41, No. 20, July 1, 2024
Eligibility provided under the Insure Oklahoma ESI program
				  may end during the eligibility period when:
(1) the employer no longer meets the
				eligibility requirements in
				317:45-7-1;
(2) the employer fails to pay
				premiums to the carrier;
(3) the
				employer fails to provide an invoice verifying the monthly benefit plan premium
				has been paid; or
(4) a review
				indicates a discrepancy that makes the employer ineligible.
Added at 23 Ok Reg 278,
				  eff 10-3-05 (emergency); Added at 23 Ok Reg 1407, eff 5-25-06; Amended at 24 Ok
				  Reg 101, eff 8-2-06 (emergency); Amended at 24 Ok Reg 700, eff 2-1-07
				  (emergency); Amended at 24 Ok Reg 2159, eff 6-25-07; Amended at 26 Ok Reg 2169,
				  eff 6-25-09; Amended at 27 Ok Reg 2391, eff 7-1-10 (emergency); Amended at 28
				  Ok Reg 1574, eff 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 9 - Insure Oklahoma ESI Employee Eligibility › Section 317:45-9-1 - Employee eligibility requirements

Current through Vol. 41, No. 20, July 1, 2024
(a) Employees must complete and submit the
				OHCA required forms and application to be considered for participation in the
				program.
(b) The eligibility
				determination will be processed within thirty (30) days from the date the
				application is received. The employee will be notified in writing of the
				eligibility decision.
(c) All
				eligible employees described in this section must be enrolled in their
				employer's qualified benefit plan. Eligible employees must:
(1) Have countable income at or below the
				appropriate standard according to the family size on the Insure Oklahoma ESI
				Income Guidelines form;
(A) Financial
				eligibility for Insure Oklahoma ESI benefits is determined using the MAGI
				methodology. Unless questionable, the income of applicants does not require
				verification. See OAC
				317:35-6-39
				through 317:35-6-55 for the applicable MAGI rules for determining household
				composition and countable income.
(B) Income is evaluated on a monthly basis
				for all individuals included in the case for Insure Oklahoma ESI
				Benefits.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 9 - Insure Oklahoma ESI Employee Eligibility › Section 317:45-9-1.1 - Certification of newborn child deemed eligible

Current through Vol. 41, No. 20, July 1, 2024
(a) A newborn child is deemed eligible on the
				date of birth for SoonerCare benefits when the child is born to a member of
				Insure Oklahoma Employer Sponsored Insurance (ESI) and the annual gross
				household income does not exceed SoonerCare requirements. The newborn child is
				deemed eligible for SoonerCare benefits through the last day of the month the
				child attains the age of one (1) year.
(b) The newborn child's SoonerCare
				eligibility is not dependent on the mother's continued eligibility in Insure
				Oklahoma ESI. The child's SoonerCare eligibility is based on the original
				eligibility determination of the mother for Insure Oklahoma ESI and
				consideration is not given to any income or resource changes that occur during
				the deemed eligibility period.
(c)
				The newborn child's certification period for SoonerCare is shortened only in
				the event the child:
(1) Loses Oklahoma
				residence; or
(2) Expires.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 9 - Insure Oklahoma ESI Employee Eligibility › Section 317:45-9-2 - Employee eligibility period

Current through Vol. 41, No. 20, July 1, 2024
(a)
				Employee eligibility is contingent upon the employer's program
				eligibility.
(b) The employee's
				eligibility is determined using the eligibility requirements listed in OAC
				317:45-9-1.
(c) If the employee is determined eligible,
				he/she is approved for a period not greater than twelve (12) months.
(d) The employee's eligibility period begins
				on the first day of the month following the date of approval.
Added at 23 Ok Reg 278,
				  eff 10-3-05 (emergency); Added at 23 Ok Reg 1407, eff 5-25-06; Amended at 26 Ok
				  Reg 2169, eff 6-25-09; Amended at 27 Ok Reg 2391, eff 7-1-10 (emergency);
				  Amended at 28 Ok Reg 1574, eff 6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 45 - Insure Oklahoma › Subchapter 9 - Insure Oklahoma ESI Employee Eligibility › Section 317:45-9-3 - Qualifying Event

Current through Vol. 41, No. 20, July 1, 2024
Employees and/or an employee's dependents may apply for the
				  ESI program following a qualifying event.
Added at 23 Ok Reg 278,
				  eff 10-3-05 (emergency); Added at 23 Ok Reg 1407, eff 5-25-06; Amended at 24 Ok
				  Reg 101, eff 8-2-06 (emergency); Amended at 24 Ok Reg 963, eff 5-11-07; Amended
				  at 26 Ok Reg 2169, eff 6-25-09; Amended at 27 Ok Reg 2391, eff 7-1-10
				  (emergency); Amended at 28 Ok Reg 1574, eff
				  6-25-11