Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 16 - State Plan Personal Care Services for Expansion Adults, TEFRA Eligible Children and Certain Magi Populations › Section 317:35-16-9 - Medical eligibility redetermination for State Plan Personal Care (SPPC) services

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