SECTION 317:30-5-764. Reimbursement

(a)   Rates for Waiver services are set in accordance with the rate-setting process by the State Plan Amendment and Rate Committee (SPARC) and approved by the Oklahoma Health Care Authority Board.

(1)   The rate for Nursing Facility (NF) respite is set equivalent to the rate for routine level of care NF services that require providers having equivalent qualifications;

(2)   The rate for daily units for Adult Day Health is set equivalent to the rate established by the Oklahoma Department of Human Services (DHS) for equivalent services provided for the (DHS) Adult Day Service Program that requires providers have equivalent qualifications.

(3)   The rate for units of home-delivered meals is are set equivalent to the rate established by the DHS for the equivalent services provided for the DHS Home-Delivered Meals Program that require providers having equivalent qualifications.

(4)   The rates for units of ADvantage Personal Care and In-Home Respite are set equivalent to State Plan Agency Personal Care unit rate that requires providers have equivalent qualifications.

(5)   The rates for Advanced Supportive/Restorative Assistance is set equivalent to 1.077 of the State Plan Agency Personal Care unit rate;

(6)   Consumer-Directed Personal Assistance Services and Supports (CD-PASS) rates are determined using the Individual Budget Allocation (IBA) Expenditure Accounts Determination process for each member. The IBA Expenditure Accounts Determination process includes consideration and decisions about the items listed in (A) - (C) of this paragraph.

(A)   The Individual Budget Allocation (IBA) Expenditure Accounts Determination constrains total Medicaid reimbursement for CD-PASS services to be less than expenditures for equivalent services using agency providers.

(B)   The PSA and APSA service unit rates are calculated by the DHS Aging Services (AS) during the CD-PASS service eligibility determination process. DHS AS sets the PSA and APSA unit rates at a level that is not less than 80 percent and not more than 95 percent of the comparable Agency Personal Care (PSA) or Advanced Supportive/Restorative (APSA)service rates. The allocation of portions of the PSA and/or APSA rates to cover salary, mandatory taxes, and optional benefits including Worker's Compensation insurance, when available, is determined individually for each member using the CD-PASS Individualized Budget Allocation (IBA) Expenditure Accounts Determination Process.

(C)   The IBA Expenditure Accounts Determination process defines the level of program financial resources required to meet the member's need for CD-PASS services. When the member's need for services changes due to a change in health/disability status and/or a change in the level of support available from other sources to meet needs, the case manager, based upon an updated assessment, amends the person-centered service plan to increase CD-PASS service units appropriate to meet additional member need. DHS AS, upon favorable review, authorizes the amended person-centered service plan and updates the member's IBA. Service amendments based on changes in member need for services do not change an existing PSA or APSA rate. The member with assistance from the FMS, reviews and revises the IBA Expenditure Accounts calculation annually or more often to the extent appropriate and necessary.

(7)   Three per diem reimbursement rate levels for the ADvantage assisted living services are set. Different rate per diem levels are established to adequately reimburse the provider for the provision of different levels of service to accommodate different level of member need for services-type, intensity and frequency to address member Activities of Daily Living and Instrumental Activities of Daily Living (ADL/IADL) and health care needs. Rounded to the nearest cent, the lowest level Assisted Living Services per diem rate is set equivalent to 11.636 times the State Plan Agency Personal Care unit rate; the mid-level per diem rate is set equivalent to 15.702 times the State Plan Agency Personal Care unit rate; and the highest level Assisted Living Services per diem rate is set equivalent to 21.964 times the State Plan Agency Personal Care unit rate. The specific rate level appropriate to a particular member's service is determined by Uniform Comprehensive Assessment Tool, Part III (UCAT III) assessment by the member's ADvantage case manager employed by a case management agency independent of the Assisted Living Services provider. ADvantage payment is not made for 24-hour skilled care in an assisted living center. Federal financial participation is not available for room and board, items of comfort or convenience, or the costs of facility maintenance, upkeep and improvement. Separate payment is not made for ADvantage services of personal care, advanced supportive/restorative assistance, skilled nursing, Personal Emergency Response System, home-delivered meals, adult day health or environmental modifications to a member while receiving assisted living services since these services are integral to and inherent in the provision of assisted living service. However, separate payment may be made for Medicaid State Plan and/or Medicare Home Health benefits to members receiving ADvantage assisted living. Separate payment is not made for ADvantage respite to a member while receiving assisted living services since by definition assisted living services assume the responsibility for 24-hour oversight/monitoring of the member, eliminating the need for informal support respite. The member is responsible for room and board costs; however, for an ADvantage member, the ADvantage assisted living services provider is allowed to charge a maximum for room and board that is no more than 90 percent of the Supplemental Security Income (SSI) Federal Benefit Rate. When, per OAC 317:35-17-1(b) and 317:35-17-11, the member has a vendor payment obligation, the provider is responsible for collecting the vendor payment from the member.

(7)   The maximum total annual reimbursement for a member's hospice care within a 12-month period is limited to an amount equivalent to 85 percent of the Medicare Hospice Cap payment.

(b)   The DHS AS approved ADvantage person-centered service plan is the basis for the Medicaid Management Information Systems (MMIS) service prior authorization, specifying the:

(1)   service;

(2)   service provider;

(3)   units authorized; and

(4)   begin and end dates of service authorization.

(c)   Service time for personal care, case management services for institution transitioning, nursing, skilled nursing, supportive/restorative assistance, and in-home respite, is documented solely through the use of the Electronic Visit Verification System (EVV), previously known as Interactive Voice Response Authentication system, when services are provided in the home. Providers are required to use the EVV system after access to the system is made available by DHS. The EVV system provides alternate backup solutions should the automated system be unavailable. In the event of EVV backup system failure, the provider documents time in accordance with their agency backup plan. The agency's backup plans are only permitted when the EVV system is unavailable.

(d)   As part of ADvantage quality assurance, provider audits evaluate whether paid claims are consistent with service plan authorizations and documentation of service provision. Evidence of paid claims not supported by service plan authorization and documentation of service provisions are given to OHCA's Program Integrity Unit for follow-up investigation.

[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 18 Ok Reg 2962, eff 5-17-01 (emergency); Amended at 19 Ok Reg 337, eff 11-14-01 (emergency); Amended at 19 Ok Reg 1067, eff 5-13-02; Amended at 20 Ok Reg 374, eff 1-1-03 (emergency); Amended at 20 Ok Reg 1920, eff 6-26-03; Amended at 22 Ok Reg 2731, eff 5-4-05 (emergency); Amended at 23 Ok Reg 1366, eff 5-25-06; Amended at 24 Ok Reg 83, eff 8-2-06 (emergency); Amended at 24 Ok Reg 932, eff 5-11-07; Amended at 25 Ok Reg 660, eff 2-1-08 through 7-14-08 (emergency); Amended at 25 Ok Reg 2685, eff 7-25-08; Amended at 26 Ok Reg 994, eff 5-1-09 (emergency); Amended at 27 Ok Reg 621, eff 1-14-10 (emergency); Amended at 27 Ok Reg 1466, eff 6-11-10; Amended at 30 Ok Reg 1179, eff 7-1-13; Amended at 34 Ok Reg 678, eff 9-1-17]

Note

EDITOR’S NOTE: This emergency action expired on 7-14-08 before being superseded by a permanent action. Upon expiration of an emergency amendatory action, the last effective permanent text is reinstated. Therefore, on 7-15-08 (after the 7-14-08 expiration of the emergency action), the text of 317:30-5-764 reverted back to the permanent text that became effective 5-11-07, as was last published in the 2007 OAC Supplement, and remained as such until amended by permanent action on 7-25-08.