SECTION 317:30-5-42.16. Related services

(a)   Ambulance. Ambulance services furnished by the facility are covered separately if otherwise compensable under the Authority's Medical Programs.

(b)   Home health care. Hospital based home health providers must be Medicare certified and have a current Home Health Agency contract with the OHCA. For home health services, a qualified provider must conduct and document a face-to-face encounter with the member in accordance with provisions of 42 CFR 440.70.

(1)   Payment is made for home health services provided in a member's residence to all categorically needy individuals.

(2)   Payment is made for a maximum of 36 visits per year for eligible members 21 years of age or older. Payment for any combination of skilled and home health aide visits can not exceed 36 visits per year.

(3)   Payment is made for standard medical supplies.

(4)   Payment is made on a rental or purchase basis for equipment and appliances suitable for use in the home.

(5)   Non-covered items include sales tax, enteral therapy and nutritional supplies, and electro-spinal orthosis systems (ESO).

(6)   Payment may be made to home health agencies for prosthetic devices.

(A)   Coverage of oxygen includes rental of liquid oxygen systems, gaseous oxygen systems and oxygen concentrators when prior authorized. Purchase of oxygen systems may be made where unusual circumstances exist and purchase is considered most appropriate.

(B)   Payment is made for permanent indwelling catheters, drain bags, insert trays and irrigation trays. Male external catheters are also covered.

(C)   Sterile tracheotomy trays are covered.

(D)   Payment is made for colostomy and urostomy bags and accessories.

(E)   Payment is made for hyperalimentation, including supplements, supplies and equipment rental on behalf of persons having permanently inoperative internal body organ dysfunction. Information regarding the member's medical condition that necessitates the hyperalimentation and the expected length of treatment, should be attached when requesting prior authorization.

(F)   Payment is made for ventilator equipment and supplies when prior authorized.

(G)   Payment for medical supplies, oxygen, and equipment is made when using appropriate HCPCS codes which are included in the HCPCS Level II Coding Manual.

(c)   Hospice Services. Hospice is defined as palliative and/or comfort care provided to the member family when a physician certifies that the member has a terminal illness and has a life expectancy of six months or less. A hospice program offers palliative and supportive care to meet the special needs arising out of the physical, emotional and spiritual stresses which are experienced during the final stages of illness and death. Hospice services must be related to the palliation and management of the member's illness, symptom control, or to enable the individual to maintain activities of daily living and basic functional skills.

(1)   Payment is made for home based hospice services for terminally ill individuals under the age of 21 with a life expectancy of six months or less when the member and/or family has elected hospice benefits. Hospice services are available to eligible members without forgoing any other service to which the member is entitled under SoonerCare for curative treatment of the terminal illness. Once the member has elected hospice care, the hospice medical team assumes responsibility for the member's medical care for the terminal illness in the home environment. Hospice providers are not responsible for curative treatments for members that elect such services while on hospice. Hospice care includes nursing care, physician services, medical equipment and supplies, drugs for symptom control and pain relief, home health aide and personal care, physical, occupational and/or speech therapy, medical social services, dietary counseling and grief and bereavement counseling to the member and/or family.

(2)   Hospice care is available for two initial 90-day periods and an unlimited number of subsequent 60-day periods during the remainder of the member's lifetime. Beginning January 1, 2011, a hospice physician or nurse practitioner must have a face to face encounter with the member to determine if the member's terminal illness necessitates continuing hospice care services. The encounter must take place prior to the 180th day recertification and each subsequent recertification thereafter; and attests that such visit took place. The member and/or the family may voluntarily terminate hospice services.

(3)   Hospice services must be reasonable and necessary for the palliation or management of a terminal illness or related conditions. A certification that the member is terminally ill must be completed by the member's attending physician or the Medical Director of an Interdisciplinary Group. Nurse practitioners serving as the attending physician may not certify the terminal illness; however, effective January 1, 2011, nurse practitioners may re-certify the terminal illness.

(4)   Services must be prior authorized. A written plan of care must be established before services are provided. The plan of care should be submitted with the prior authorization request.

[Source: Added at 24 Ok Reg 317, eff 12-1-06 (emergency); Added at 24 Ok Reg 905, eff 5-11-07; Amended at 28 Ok Reg 511, eff 1-6-11 (emergency); Amended at 28 Ok Reg 1489, eff 6-25-11; Amended at 34 Ok Reg 672, eff 9-1-17]