reglab/statecodes huggingface dataset:
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 18 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 317:35-18-6 - PACE program benefits

Current through Vol. 41, No. 20, July 1, 2024
(a)
				The PACE program offers a comprehensive benefit plan. A provider agency must
				provide a participant all the services listed in Section (§) 460.92 of
				Title 42 of the Code of Federal Regulations (C.F.R.) that are approved by the
				interdisciplinary team (IDT). The PACE benefit package for all participants,
				regardless of the source of payment, must include but is not limited to the
				following:
(1) All SoonerCare-covered
				services, as specified in the State's approved Medicaid State Plan;
(2) IDT and treatment planning;
(3) Primary care, including physician and
				nursing services;
(4) Social work
				services;
(5) Restorative
				therapies, including physical therapy, occupational therapy, and
				speech-language pathology services;
(6) Personal care and supportive services;
(7) Nutritional counseling;
(8) Recreational therapy;
(9) Transportation;
(10) Meals;
(11) Medical specialty services including,
				but not limited to the following:
(A)
				Anesthesiology;
(B) Audiology;
(C) Cardiology;
(D) Dentistry;
(E) Dermatology;
(F) Gastroenterology;
(G) Gynecology;
(H) Internal medicine;
(I) Nephrology;
(J) Neurosurgery;
(K) Oncology;
(L) Ophthalmology;
(M) Oral surgery;
(N) Orthopedic surgery;
(O) Otorhinolaryngology;
(P) Plastic surgery;
(Q) Pharmacy consulting services;
(R) Podiatry;
(S) Psychiatry;
(T) Pulmonary disease;
(U) Radiology;
(V) Rheumatology;
(W) General surgery;
(X) Thoracic and vascular surgery; and
(Y) Urology.
(12) Laboratory tests, x-rays, and other
				diagnostic procedures;
(13) Drugs
				and biologicals;
(14) Prosthetics,
				orthotics, medical supplies, equipment, and appliances, corrective vision
				devices, such as eyeglasses and lenses, hearing aids, dentures, and repair and
				maintenance of these items;
(15)
				Acute inpatient care, including the following:
(A) Ambulance;
(B) Emergency room care and treatment room
				services;
(C) Semi-private room
				and board;
(D) General medical and
				nursing services;
(E) Medical
				surgical/intensive care/coronary care unit;
(F) Laboratory tests, x-rays, and other
				diagnostic procedures;
(G) Drugs
				and biologicals;
(H) Blood and
				blood derivatives;
(I) Surgical
				care, including the use of anesthesia;
(J) Use of oxygen;
(K) Physical, occupational, respiratory
				therapies, and speech-language pathology services; and
(L) Social services.
(16) Nursing facility(NF) care, including:
(A) Semi-private room and board;
(B) Physician and skilled nursing services;
(C) Custodial care;
(D) Personal care and assistance;
(E) Drugs and biologicals;
(F) Physical, occupational, recreational
				therapies, and speech-language pathology, if necessary;
(G) Social services; and
(H) Medical supplies, equipment, and
				appliances.
(17) Other
				services determined necessary by the IDT to improve and maintain the
				participant's overall health status.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 18 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 317:35-18-7 - Programs of All-Inclusive for the Elderly (PACE) organization's appeals process

Current through Vol. 41, No. 20, July 1, 2024
(a) Internal
				appeals:
(1) Any individual who is denied
				program services is entitled to an appeal through the provider.
(2) If the individual also chooses to file an
				external appeal, the provider must assist the individual in filing an external
				appeal.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 18 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 317:35-18-8 - Enrollment

Current through Vol. 41, No. 20, July 1, 2024
(a) The provider
				determines whether the applicant meets PACE enrollment requirements.
(b) The enrollment effective date is the
				first day of the month after the provider receives the signed enrollment form.
(c) Enrollment continues until the
				participant's death, regardless of changes in health status, unless either of
				the following actions occur:
(1) The
				participant voluntarily disenrolls and/or elects to transfer to other eligible
				PACE program.
(2) The participant
				is involuntarily disenrolled.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 18 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 317:35-18-9 - Continuation of enrollment

Current through Vol. 41, No. 20, July 1, 2024
(a) At
				least annually, OHCA must reevaluate whether a participant continues to meet
				the level of care required for PACE eligibility.
(b) At least annually, OKDHS will reevaluate
				the participant's financial eligibility for SoonerCare.
(1) Waiver of Annual level of Care
				Reassessment. If the individual meets the state's medical eligibility criteria
				and the individual has an irreversible or progressive diagnosis or a terminal
				illness that could reasonably be expected to result in death in the next six
				months, and OHCA determines that there is no reasonable expectation of
				improvement or significant change in the condition because of severity of a
				chronic condition or the degree of impairment of functional capacity, OHCA will
				permanently waive the annual recertification requirement and the participant
				will be deemed to be continually eligible for PACE. The assessment form must
				have sufficient documentation to substantiate the participant's prognosis and
				functional capacity.
(2) Deemed
				Continued Eligibility. If it is determined that a PACE participant no longer
				meets the medical criteria for nursing facility level of care, the participant
				will be deemed to continue to be eligible for PACE until the next annual
				reassessment, if, in the absence of PACE services, it is reasonable to expect
				that the participant would meet the nursing facility level of care criteria
				within the next six months.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 18 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 317:35-18-10 - Disenrollment (voluntary and involuntary)

Current through Vol. 41, No. 20, July 1, 2024
(a) A participant may voluntarily disenroll
				from PACE at any time without cause however, the effective date of
				disenrollment must be the last day of the month that the participant elects to
				disenroll.
(b) A participant may be
				involuntarily disenrolled for any of the following reasons:
(1) The participant/caregiver or guardian
				fails to pay, or to make satisfactory arrangements to pay, any premium due the
				PACE organization after a 30-day grace period.
(2) The participant/caregiver or guardian
				engages in disruptive or threatening behavior, as described in subsection (c)
				of this section.
(3) The
				participant moves out of the PACE program service area or is out of the service
				area for more than 30 consecutive days, unless the PACE organization agrees to
				a longer absence due to extenuating circumstances.
(4) The participant is determined to no
				longer meet the SoonerCare nursing facility level of care requirements and is
				not deemed eligible.
(5) The PACE
				program agreement with CMS and OHCA is not renewed or is terminated.
(6) The PACE organization is unable to offer
				health care services due to the loss of State licenses or contracts with
				outside providers.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 18 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 317:35-18-11 - Data collection and reporting

Current through Vol. 41, No. 20, July 1, 2024
The PACE provider must:
(1) collect data to comply with reporting
				requirements in provider application;
(2) generate and maintain monthly reports
				from collected data;
(3) make the
				reports available to the OHCA; and
(4) comply with all data requests as
				specified by the OHCA within 30 days of such requests.
Added at 23 Ok Reg 2583,
				  eff 6-25-06; Amended at 29 Ok Reg 1189, eff
				  6-25-12
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 18 - Programs of All-Inclusive Care for the Elderly (PACE) › Section 317:35-18-12 - Medicaid Payments

Current through Vol. 41, No. 20, July 1, 2024
(a) The OHCA makes
				a prospective monthly payment to the PACE organization of a capitation amount
				for each Medicaid participant.
(b)
				The payment amount represents:
(1) is less
				than the amount that would otherwise have been paid under the State plan if the
				participants were not enrolled under the PACE program.
(2) Takes into account the comparative
				frailty of PACE participant.
(3) is
				a fixed amount regardless of changes in the participant's health
				status.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-1 - Implementation of gatekeeping in NF [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
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; Revoked at 15 Ok Reg 3715, eff 5-18-98 (emergency); Revoked at 16
				  Ok Reg 1438, eff 5-27-99
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-3 - Services in a Nursing Facility (NF)

Current through Vol. 41, No. 20, July 1, 2024
(a) Nursing facility services are those
				services furnished pursuant to a physician's orders which require the skills of
				technical or professional personnel, e.g., registered nurses, licensed
				practical nurses, physical therapists, occupational therapists, speech
				pathologists or audiologists. The care is provided by nursing facilities
				licensed under state law to provide, on a regular basis, health related care
				and services to individuals who do not require hospitalization but whose
				physical or mental condition requires care and services above the level of room
				and board which can be made available to them only through a nursing facility.
				To be eligible for nursing facility services, the UCAT demonstrates the
				individual must:
(1) require a treatment plan
				involving the planning and administration of services which require skills of
				licensed technical or professional personnel that are provided directly or
				under the supervision of such personnel and are prescribed by the
				physician;
(2) have a physical
				impairment or combination of physical and mental impairments;
(3) require professional nursing supervision
				(medication, hygiene and dietary assistance);
(4) lack the ability to care for self or
				communicate needs to others; and
(5) require medical care and treatment in a
				nursing facility to minimize physical health regression and deterioration. A
				physician's order and results from a standardized assessment which evaluates
				type and degree of disability and need for treatment must support the
				individual's need for NF level of care. Only standardized assessments approved
				by the OHCA and administered in accordance with Medicaid approved procedures
				shall be used to make the NF level of care determination.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-4 - Medicaid recovery

Current through Vol. 41, No. 20, July 1, 2024
(a)
General
				overview.
The Omnibus Budget Reconciliation Act of 1993 mandates the
				state to seek recovery against the estate of certain Title XIX members who
				received medical care on or after July 1, 1994, and who were 55 years of age or
				older when the care was received. The payment of Title XIX by the Oklahoma
				Health Care Authority (OHCA) on behalf of a member who is an inpatient of a
				nursing facility, intermediate care facility for the mentally retarded or other
				medical institution creates a debt to the OHCA subject to recovery by legal
				action either in the form of a lien filed against the real property of the
				member and/or a claim made against the estate of the member. Only Title XIX
				received on or after July 1, 1994, will be subject to provisions of this part.
				Recovery for payments made under Title XIX for nursing care is limited by
				several factors, including the family composition at the time the lien is
				imposed and/or at the time of the member's death and by the creation of undue
				hardship at the time the lien is imposed or the claim is made against the
				estate. [See OAC
				317:35-5-41.8(a)(3)(H)
				for consideration of home property as a countable resource.] State Supplemental
				Payments are not considered when determining the countable income. The types of
				medical care for which recovery can be sought include:
(1) nursing facility services,
(2) home and community based
				services,
(3) related hospital
				services,
(4) prescription drug
				services,
(5) physician services,
				and
(6) transportation
				services.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-5 - Application for nursing facility care; forms

Current through Vol. 41, No. 20, July 1, 2024
(a)
Application procedures for nursing
				facility care.
An application for Nursing Facility (NF) level of care
				consists of the Medical Assistance Application form. The form is signed by the
				client, parent, spouse, guardian or someone else acting on the client's behalf.
(1) All conditions of eligibility must be
				verified and documented in the case record. When current information already
				available in the local office establishes eligibility, such information may be
				used by recording source and date of information.
(2) At the request of an individual in an NF
				or the community spouse, if application for Medicaid is not being made, an
				assessment of the resources available to each spouse is made by use of DHS form
				MA-11, Assessment of Assets. Documentation of resources must be provided by the
				individual and/or spouse. This assessment reflects all countable resources of
				the couple (owned individually or as a couple) and establishes the spousal
				share to be protected when subsequent determination of Medicaid eligibility is
				made. A copy of Form MA-11 is provided to each spouse for planning in regard to
				future eligibility. A copy is retained in the county office in case of
				subsequent application.
(3) If
				assessment by Form MA-11 was not done at the time of entry into the nursing
				home, assessment by use of Form MA-11 must be done at the time of application
				for Medicaid. The spousal share of resources is determined for the month of
				entry into the nursing home. If the individual applies for Medicaid at the time
				of entry into the nursing home, Form MA-11 is not appropriate. However, the
				spousal share must be determined using the resource information provided on the
				Medicaid application form and computed using Form MA-12, Title XIX
				Worksheet.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-6 - Application procedures for NF

Current through Vol. 41, No. 20, July 1, 2024
Individuals may apply for nursing home care at the OKDHS
				  human services center (HSC) of their choice. A written application is not
				  required for an individual who has an active SoonerCare case. For NF, OKDHS
				  Form 08MA083E, Notification Regarding Patient in a Nursing Facility,
				  Intermediate Care Facility for the Mentally Retarded or Hospice form, when
				  received in the HSC, also constitutes an application request and is handled the
				  same as an oral request.
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 17 Ok Reg 2410, eff 6-26-00; Amended at 26 Ok Reg 408,
				  eff 1-1-09 (emergency); Amended at 26 Ok Reg 2139, eff
				  6-25-09
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-7 - Determination of medical eligibility for care in NF [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
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;
				  Revoked at 14 Ok Reg 56, eff 4-30-96 (emergency); Revoked at 14 Ok Reg 1802,
				  eff 5-27-97
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-7.1 - Level of care medical eligibility determination

Current through Vol. 41, No. 20, July 1, 2024
The OKDHS area nurse, or nurse designee (OHCA, LOCEU makes
				  some determinations when PASRR is involved), determines medical eligibility for
				  the ADvantage program or nursing facility services based on the LTC nurse's
				  UCAT III assessment, outcome of the Level II PASRR, if completed, and
				  professional judgment.
(1)
Definitions.
The following words and terms when used in this
				subchapter, shall have the following meaning, unless the context clearly
				indicates otherwise:
(A)
"ADL"
means the activities of daily living. Activities of daily living are activities
				that reflect the client's ability to perform self-care tasks essential for
				sustaining health and safety such as:
(i)
				bathing,
(ii) eating,
(iii) dressing,
(iv) grooming,
(v) transferring (includes getting in and out
				of a tub, bed to chair, etc.),
(vi)
				mobility,
(vii) toileting,
				and
(viii) bowel/bladder
				control.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-8 - Preadmission screening and resident review

Current through Vol. 41, No. 20, July 1, 2024
(a) Federal regulations govern the State's
				responsibility for Preadmission Screening and Resident Review (PASRR) of
				individuals with mental illness and intellectual disabilities. PASRR applies to
				the screening or reviewing of all individuals for mental illness, intellectual
				disability, or related conditions who apply to or reside in a Title XIX
				certified nursing facility (NF), regardless of the source of payment for the NF
				services and/or the individual's or resident's known diagnoses. Individuals
				referred for admission to a NF must be screened for a major mental disorder,
				diagnosable under the most current edition of the Diagnostic and Statistical
				Manual of Mental Disorders (DSM). The NF must independently evaluate the Level
				I PASRR screen regardless of who completes the form and determine whether or
				not to admit an individual to the facility. If an individual is admitted
				inappropriately, the NF is subject to recoupment of Medicaid funds and
				penalties imposed by the Centers for Medicare and Medicaid Services (CMS).
				Federal financial participation (FFP) may not be paid until results of any
				needed PASRR Level II evaluations are received. PASRR is a requirement for
				nursing facilities with dually certified (both Medicare and Medicaid) beds.
				There are no PASRR requirements for Medicare skilled beds that are not dually
				certified, nor is PASRR required for individuals seeking residency in an
				intermediate care facility for individuals with intellectual disabilities
				(ICF/IID).
(b) For Medicaid
				applicants, medical and financial eligibility determinations are also
				required.
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 17 Ok Reg 2410, eff 6-26-00; Amended at 23 Ok Reg 2586,
				  eff 6-25-06; Amended at 29 Ok Reg 1162, eff
				  6-25-12
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-9 - PASRR screening process

Current through Vol. 41, No. 20, July 1, 2024
(a)
Level I screen for PASRR.
(1)
				OHCA Form LTC-300R, Nursing Facility Level of Care Assessment, must be
				completed by an authorized NF official or designee. An authorized NF official
				or designee must consist of one of the following:
(A) The NF administrator or
				co-administrator;
(B) A licensed
				nurse, social service director, or social worker from the facility;or
(C) A licensed nurse, social
				service director, or social worker from the hospital.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-10 - Level II screen for PAS [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
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;
				  Revoked at 14 Ok Reg 56, eff 4-30-96 (emergency); Revoked at 14 Ok Reg 1802,
				  eff 5-27-97
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-11 - Annual Resident Review (ARR) [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
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;
				  Revoked at 14 Ok Reg 56, eff 4-30-96 (emergency); Revoked at 14 Ok Reg 1802,
				  eff 5-27-97
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-12 - Level I screen for ARR [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
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;
				  Revoked at 14 Ok Reg 56, eff 4-30-96 (emergency); Revoked at 14 Ok Reg 1802,
				  eff 5-27-97
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-13 - Level II screen for ARR [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
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;
				  Revoked at 14 Ok Reg 56, eff 4-30-96 (emergency); Revoked at 14 Ok Reg 1802,
				  eff 5-27-97
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-14 - New admissions, readmissions, interfacility transfers, and same level of care program transfers

Current through Vol. 41, No. 20, July 1, 2024
The Preadmission Screening process does not apply to
				  readmission of an individual back to the same NF following a continuous medical
				  hospital stay. There is no specific time limit on the length of absence from
				  the nursing facility for the hospitalization. Inter-facility transfers are also
				  subject to preadmission screening. In the case of transfer of a resident from
				  an NF to a hospital or to another NF, the transferring NF is responsible for
				  ensuring that copies of the resident's most recent PASRR Form LTC-300R and any
				  PASRR evaluations accompany the transferring resident. The receiving NF must
				  submit an updated Form LTC-300R that reflects the resident's current status to
				  LOCEU within 10 days of the transfer. Failure to do so could result in
				  recoupment of funds.
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 17 Ok Reg 2410, eff 6-26-00; Amended at 22 Ok Reg 108,
				  eff 7-1-04 (emergency); Amended at 22 Ok Reg 2527, eff 7-11-05; Amended at 23
				  Ok Reg 2586, eff 6-25-06; Amended at 24 Ok Reg 2866, eff 6-1-07 (emergency);
				  Amended at 25 Ok Reg 1227, eff 5-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-15 - PASARR tracking system [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
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;
				  Revoked at 14 Ok Reg 56, eff 4-30-96 (emergency); Revoked at 14 Ok Reg 1802,
				  eff 5-27-97
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-16 - PASRR appeals process

Current through Vol. 41, No. 20, July 1, 2024
(a)
				Any individual who has been adversely affected by any Preadmission Screening
				and Resident Review (PASRR) determination made by the State in the context of
				either a preadmission screening or an annual resident review may appeal that
				determination by requesting a fair hearing. If the individual does not consider
				the PASRR decision a proper one, the individual or their authorized
				representative must contact the local county Oklahoma Department of Human
				Services (DHS) office to discuss a hearing. Forms for requesting a fair hearing
				(DHS Form 13MP001E, Request for a Fair Hearing), as well as assistance in
				completing the forms, can be obtained at the local county DHS office. Any
				request for a hearing must be made no later than thirty (30) days following the
				date of written notice. Appeals of these decisions are available under Oklahoma
				Administrative Code (OAC)
				317:2-1-2. There is no
				distinction between the SoonerCare and non-SoonerCare patient; therefore, all
				individuals seeking an appeal have the same rights, regardless of source of
				payment. Level I determinations are not subject to appeal.
(b) When the individual is found to
				experience Mental Illness (MI), Intellectual Disability (ID), or related
				condition through the Level II screen, the PASRR determination made by the
				ID/MI authorities cannot be countermanded by the Oklahoma Health Care
				Authority, either in the claims process or through other utilization
				control/review processes, or by the Oklahoma State Department of Health. Only
				appeals determinations made through the fair hearing process may overturn a
				PASRR determination made by the ID/MI authorities.
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 17 Ok Reg 2410, eff 6-26-00; Amended at 23 Ok Reg 817,
				  eff 3-9-06 (emergency); Amended at 23 Ok Reg 2586, eff 6-25-06; Amended at 24
				  Ok Reg 2866, eff 6-1-07 (emergency); Amended at 25 Ok Reg 1227, eff
				  5-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-17 - Determination of continued medical eligibility for care in a nursing facility [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
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;
				  Revoked at 14 Ok Reg 56, eff 4-30-96 (emergency); Revoked at 14 Ok Reg 1802,
				  eff 5-27-97
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-18 - Change in level of long-term medical care

Current through Vol. 41, No. 20, July 1, 2024
(a) When a member is receiving Personal Care
				services and requests nursing facility care or when a member is in a nursing
				facility and requests Personal Care services, a new Uniform Comprehensive
				Assessment Tool (UCAT) is required. The UCAT is updated if the member is in the
				nursing facility and requests ADvantage waiver services. No new medical
				decision is needed. Also, no new medical decision is needed for admission to a
				nursing facility from home if the period of absence from the nursing facility
				is less than 90 days. No new medical decision is needed if the member loses
				financial eligibility but maintains medical eligibility by having a current
				medical decision and by remaining in the facility during the period of
				financial ineligibility.
(b) When
				there is a decision that a member approved for one level of long term care is
				eligible for a different level of care, the local office is advised by update
				of the file. If the change is from facility care to Personal Care, a new UCAT,
				Part III care plan, service plan, and other required forms are submitted to the
				area nurse, or nurse designee. If the Personal Care member requests a decision
				regarding facility care prior to admission to a facility, the LTC nurse is
				responsible for submitting the UCAT, Part III, and Form LTC-300R to the area
				nurse, or nurse designee for a decision. When the area nurse, or nurse
				designee, determines that a nursing care member no longer needs this level of
				care, payment may be continued while the member, or other responsible person,
				makes other arrangements. The length of such continuation of payment depends
				upon the circumstances, but must allow time for the appropriate advance notice
				to the member and cannot exceed 60 days from the date of the
				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 5-18-98 (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; Amended at 24
				  Ok Reg 2866, eff 6-1-07 (emergency); Amended at 25 Ok Reg 1227, eff
				  5-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-19 - General financial eligibility requirements for NF and skilled nursing care

Current through Vol. 41, No. 20, July 1, 2024
(a)
Financial
				eligibility for NF care.
Financial eligibility for NF care is determined
				using the rules on income and resources according to the eligibility group to
				which the individual is related.
(1) Income,
				resources and expenses are evaluated on a monthly basis for all individuals
				requesting payment for NF care. Each individual requesting payment for NF care
				is allowed a personal needs allowance.
(2) To be eligible for long-term care in an
				NF, the individual must be determined categorically needy according to the
				standards appropriate to the categorical relationship.
(3) If the individual's gross income exceeds
				the categorically needy standard as shown on OKDHS Appendix C-1, Schedule VIII.
				B. 1., refer to OAC
				317:35-5-41.6(a)(6)(B)
				for rules on establishing a Medicaid Income Pension Trust.
(4) When eligibility for long-term care has
				been determined, the spenddown amount is determined based on type of care,
				categorical relationship, community spouse, etc.
(5) The spenddown is applied to the vendor
				payment on the first NF claim(s) received on behalf of the
				individual.
(6) For an individual
				eligible for long-term care in a NF, the individual's share of the vendor
				payment is not prorated over the month. As SoonerCare is the payer of last
				resort, the full amount of the member's share of the vendor payment must first
				be applied to the facility's charges before SoonerCare reimbursement
				begins.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-20 - Determining financial eligibility of categorically needy individuals

Current through Vol. 41, No. 20, July 1, 2024
Financial eligibility for NF medical care is determined as
				  follows:
(1)
Financial
				eligibility for MAGI eligibility groups.
See MAGI eligibility rules in
				Subchapter 6 of this Chapter to determine financial eligibility for MAGI
				eligibility groups.
(2)
Financial eligibility/categorically related to ABD.
In determining
				income and resources for the individual related to ABD, the "family" includes
				the individual and spouse, if any. If an individual and spouse cease to live
				together for reasons other than institutionalization, income and resources are
				considered available to each other through the month in which they are
				separated. Mutual consideration ceases with the month after the month in which
				the separation occurs. Any amounts which are actually contributed to the spouse
				after the mutual consideration has ended are considered. If the individual and
				spouse cease to live together because of the individual entering a nursing
				facility, see paragraph (3) of OAC
				317:35-19-21
				to determine financial eligibility.
(A) The
				categorically needy standard on OKDHS Appendix C-1, Schedule VI., is applicable
				for individuals related to ABD. If the individual is in an NF and has received
				services for 30 days or longer, the categorically needy standard in OKDHS
				Appendix C-1, Schedule VIII. B.1., is used. If the individual leaves the
				facility prior to the 30 days, or does not require services past the 30 days,
				the categorically needy standard in OKDHS Appendix C-1, Schedule VI., is used.
				The rules on determination of income and resources are applicable only when an
				individual has entered a NF and is likely to remain under care for 30
				consecutive days. The 30-day requirement is considered to have been met even if
				it is interrupted by a hospital stay or the individual is deceased before the
				30-day period ends.
(B) An
				individual who is a patient in an extended care facility may have SSI continued
				for a three month period if he/she meets conditions described in Sub-chapter 5
				of this Chapter. The continuation of the payments is intended for use of the
				member and does not affect the vendor payment. If the institutional stay
				exceeds the three month period, SSI will make the appropriate
				change.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-22 - Certification for Nursing Facility (NF)

Current through Vol. 41, No. 20, July 1, 2024
(a)
Application date.
The date
				of the application for NF care is most important in determining the date of
				eligibility. If the applicant is found eligible for SoonerCare, certification
				may be made retroactive for any service provided on or after the first day of
				the third month prior to the month of application and for future
				months.
(b)
Time limited
				approvals for nursing care.
A medical certification period of a specific
				length may be assigned for an individual who is categorically related to Aged,
				Blind and Disabled or Aid to Families with Dependent Children. This time limit
				is noted on the system. It is the responsibility of the nursing facility to
				notify the area nurse thirty (30) days prior to the end of the certification
				period if an extension of approval is required by the client. Based on the
				information from the NF the area nurse, or nurse designee, determines whether
				or not an update of the Uniform Comprehensive Tool (UCAT) is necessary for the
				extension. The area nurse, or nurse designee, coordinates with appropriate
				staff for any request for further UCAT assessments.
(c)
Certification period for long-term
				medical care.
A financial certification period of twelve (12) months is
				assigned for an individual who is approved for long-term care.
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 5-18-98 (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 ; Amended at 23 Ok Reg
					 268, eff 9-1-05 (emergency) ; Amended at 23 Ok Reg 1378, eff 5-25-06 ; Amended
					 at 30 Ok Reg 1209, eff 7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-22.1 - Discharge planning

Current through Vol. 41, No. 20, July 1, 2024
Nursing facilities are responsible for the discharge planning
				  of residents. In some instances the NF may be unable to successfully plan the
				  discharge of the private pay resident who has exhausted financial resources to
				  pay for NF care. When a private pay applicant who has exhausted resources is
				  denied medical eligibility, and the NF is unable to successfully plan for
				  discharge, the NF may request the assistance of the social worker, LTC nurse,
				  or APS worker to participate on an interdisciplinary team to develop an
				  appropriate discharge plan, or to request reconsideration of medical
				  eligibility. Other persons who may participate on the interdisciplinary team
				  are the physician, social worker, discharge planner, ombudsman, family members
				  or responsible party and the resident. The NF is responsible for convening an
				  Interdisciplinary Team meeting. A DHS team member documents the outcome of the
				  team meeting and submits it to the DHS area nurse for consideration of
				  submission to the Medicaid Director of the Oklahoma Health Care
				  Authority.
Added at 14 Ok Reg 56,
				  eff 4-30-96 (emergency); Added at 14 Ok Reg 1802, eff 5-27-97; Amended at 15 Ok
				  Reg 3715, eff 5-18-98 (emergency); Amended at 16 Ok Reg 1438, eff 5-27-99;
				  Amended at 17 Ok Reg 2410, eff 6-26-00
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-23 - Redetermination of eligibility for NF care

Current through Vol. 41, No. 20, July 1, 2024
A redetermination of financial eligibility must be completed
				  prior to the end of the certification period. A notice is generated only if
				  there is a change which affects the client's financial
				  responsibility.
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
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-24 - Case transfer between categories

Current through Vol. 41, No. 20, July 1, 2024
If it becomes necessary to transfer a Medicaid long-term care
				  case from one category to another because of change of age, income, or marital
				  status, a new application is not required. If someone other than the client or
				  guardian signed the original application form and the transfer is to a money
				  payment case, an application with the client's signature is required. The new
				  case is certified retaining the original certification date and redetermination
				  date, using the appropriate code for transfer from the old category and the
				  appropriate effective date which coincides with the closure of the previous
				  case category. Recipients and appropriate medical providers are notified of the
				  new case number and category by computer generated notice.
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 17 Ok Reg 2410, eff
				  6-26-00
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-25 - Case changes

Current through Vol. 41, No. 20, July 1, 2024
Any time there are changes which affect the long-term care
				  case, computer generated notices are issued.
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
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-26 - Payment to NF

Current through Vol. 41, No. 20, July 1, 2024
The OHCA may execute agreements to provide care only with
				  facilities which are properly licensed by the state licensing agency. The
				  agreement is initiated by application from the facility and expires on a
				  specified date, or with termination of the facility license, or shall be
				  automatically terminated on notice to this Authority that the facility is not
				  in compliance with Medicaid (or other federal long-term care)
				  requirements.
(1) In the event that a
				facility changes ownership, the agreement with the previous owner may be
				extended to the new owner, pending certification of the new owner to provide
				care to individuals during the change of ownership. In the event that the new
				owner is not showing good faith in pursuit of certification, the OHCA will
				begin planning for alternate placement of Medicaid patients. The county office
				is immediately notified of any relevant change in facility status.
(2) Payment for long-term care is made only
				for those individuals who have been approved by the Department of Human
				Services for such care. The amount of payment is based on the actual time the
				individual received care (including therapeutic leave) from a nursing facility
				during any given month. Payment for nursing care cannot be made for any period
				during which the care has been temporarily interrupted for reasons other than
				therapeutic leave. Therapeutic leave is any planned leave other than
				hospitalization that is for the benefit of the patient. Therapeutic leave must
				be clearly documented in the patient's plan of care before payment for a
				reserved bed can be made by the OHCA.
(3) Effective July 1, 1994, the nursing
				facility may receive payment for a maximum of seven days of therapeutic leave
				per calendar year for each eligible individual to reserve the bed.
(4) The Statement of Compensable Therapeutic
				Leave Only form is used by the facility to record use of therapeutic leave.
				This form is to be made available by the local office to the nursing facility
				upon request.
(5) No payment shall
				be made for hospital leave.
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 13 Ok Reg 927, eff 8-1-95 (emergency); Amended at 13 Ok Reg 415, eff
				  1-1-96 (emergency); Amended at 14 Ok Reg 56, eff 4-30-96 (emergency); Amended
				  at 13 Ok Reg 1677, eff 5-27-96; Amended at 14 Ok Reg 1802, eff 5-27-97; Amended
				  at 17 Ok Reg 2410, eff 6-26-00
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 19 - Nursing Facility Services › Section 317:35-19-27 - Billing procedures for NF

Current through Vol. 41, No. 20, July 1, 2024
Billing procedures for NF are contained in the Medical
				  Services Provider Manuals with procedures developed for each type of medical
				  provider. Questions regarding billing procedures which cannot be resolved
				  through a study of these manuals should be referred to the
				  OHCA.
Added at 12 Ok Reg 753,
				  eff 1-6-95 through 7-145-95 (emergency); Added at 12 Ok Reg 3133, eff
				  7-27-95