SECTION 317:30-5-122. Levels of care

(a)   This rule sets forth the criteria used to determine whether an individual who is seeking SoonerCare payment for long term care services needs services at the level of Skilled Nursing Facility, or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). The criteria set forth in this Section must be used when determining level of care for individuals seeking SoonerCare coverage of either facility-based institutional long term care services or Home and Community Based Services (HCBS) Waivers.

(b)   The level of care provided by a long term care facility or through a HCBS Waiver is based on the nature of the person's needs and the care, services, and treatment required from appropriately qualified personnel. The level of care review is a determination of an individual's physical, mental, and social/emotional status to determine the appropriate level of care required. In addition to level of care requirements, other applicable eligibility criteria must be met.

(1)   Skilled Nursing facility. Payment is made for the Part A coinsurance and deductible for Medicare covered skilled nursing facility care for dually eligible, categorically needy individuals.

(2)   Nursing Facility. Care provided by a nursing facility to members who require professional nursing supervision and a maximum amount of nonprofessional nursing care due to physical conditions or a combination of physical and mental conditions.

(3)   Intermediate Care Facility for Individuals with Intellectual Disabilities. Care for persons with intellectual disabilities or related conditions to provide health and/or habilitative services in a protected residential setting. To qualify for ICF/IID level of care, persons must have substantial functional limitations in three or more of the following areas of major life activity:

(A)   Self-care. The individual requires assistance, training, or supervision to eat, dress, groom, bathe, or use the toilet.

(B)   Understanding and use of language. The individual lacks functional communication skills, requires the use of assistive devices to communicate, does not demonstrate an understanding of requests, or is unable to follow two-step instructions.

(C)   Learning. The individual has a valid diagnosis of intellectual disability as defined in the Diagnostic and Statistical Manual of Mental Disorders.

(D)   Mobility. The individual requires the use of assistive devices to be mobile and cannot physically self-evacuate from a building during an emergency without assistive device.

(E)   Self-direction. The individual is seven (7) years old or older and significantly at risk in making age appropriate decisions or an adult who is unable to provide informed consent for medical care, personal safety, or for legal, financial, habilitative, or residential issues, and/or has been declared legally incompetent. The individual is a danger to himself or others without supervision.

(F)   Capacity for independent living. The individual who is seven (7) years old or older and is unable to locate and use a telephone, cross the street safely, or understand that it is unsafe to accept rides, food, or money from strangers. Or an adult who lacks basic skills in the areas of shopping, preparing food, housekeeping, or paying bills.

[Source: Added at 12 Ok Reg 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff 7-27-95; Amended at 13 Ok Reg 1203, eff 1-9-95 (emergency); Amended at 13 Ok Reg 2523, eff 6-27-96; Amended at 19 Ok Reg 2938, eff 7-1-02 (emergency); Amended at 20 Ok Reg 1193, eff 5-27-03; Amended at 23 Ok Reg 263, eff 10-3-05 (emergency); Added at 23 Ok Reg 1356, eff 5-25-06; Amended at 26 Ok Reg 248, eff 12-1-08 (emergency); Amended at 26 Ok Reg 1052, eff 5-11-09; Amended at 28 Ok Reg 1409, eff 6-25-11; Amended at 29 Ok Reg 1076, eff 6-25-12; Amended at 30 Ok Reg 371, eff 1-28-13 (emergency); Amended at 30 Ok Reg 1123, eff 7-1-13; Amended at 34 Ok Reg 626, eff 9-1-17]