SECTION 317:35-15-10. Redetermination of medical eligibility for personal care services

(a)   Medical eligibility redetermination. The Oklahoma Department of Human Services (DHS) area nurse must complete a redetermination of medical eligibility before the end of the long-term care medical certification period.

(b)   Recertification. The DHS nurse re-assesses the personal care services member, 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) Part III at least every thirty-six (36) months. Those members, who are younger than eighteen (18) years of age, are re-evaluated by the DHS nurse using the UCAT Part III on a twelve (12) month basis or sooner when needed. During this re-certification assessment, the DHS nurse informs the member of the state's other SoonerCare (Medicaid) long-term care options. The DHS nurse submits the re-assessment to the DHS area nurse for recertification. Documentation is sent to the DHS area nurse no later than the tenth-calendar (10^th-calendar) day of the month in which the certification expires. When the DHS area nurse determines medical eligibility for personal care services, a recertification review date is entered on the system.

(c)   Change in amount of units or tasks. When the personal care provider agency determines a need for a change in the amount of units or tasks within the personal care service, a new Service Authorization Model (SAM) packet is completed and submitted to DHS within five (5) business days of identifying the assessed need. The change is approved or denied by the DHS area nurse or designee, prior to implementation.

(d)   Voluntary closure of personal care services. When a member decides personal care services are no longer needed to meet his or her needs, a medical decision is not needed. The member and the DHS nurse or DHS county Social Services Specialist completes and signs DHS Form 02AG038E, State Plan Personal Care/ADvantage Program Voluntary Withdrawal Request. The DHS nurse submits closure notification to the provider agency.

(e)   Resuming personal care services. When a member approved for personal care services is without personal care services for less than ninety-calendar (90-calendar) days but has current medical and SoonerCare (Medicaid) financial eligibility approval, personal care services may be resumed using the member's previously approved SAM packet. 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 makes a home visit and submits a personal care services skilled nursing re-assessment of need within ten-business (10-business) days of the resumed plan start date, using the State Plan Personal Care Progress Notes, DHS Form 02AG044E. When the member's needs dictate, the personal care provider agency may submit a request for a change in authorized personal care services units with a SAM packet to DHS. When no changes occur, the agency nurse documents the contact on State Plan Personal Provider Communication Form 02AG032E and forwards it to the DHS nurse within ten-business (10-business) days of the resumed plan start date.

(f)   Financial ineligibility. When the DHS determines a personal care services member does not meet SoonerCare financial eligibility criteria, the DHS office notifies the DHS area nurse to initiate the closure process due to financial ineligibility. Individuals determined financially ineligible for personal care services are notified by DHS in writing of the determination and of their right to appeal the decision. The DHS nurse submits closure notification to the provider agency.

(g)   Closure due to medical ineligibility. Individuals determined medically ineligible for personal care services are notified by DHS in writing of the determination and of their right to appeal the decision. When medical eligibility redetermination is not made prior to current medical eligibility expiration, the existing medical eligibility certification is automatically extended until level of care 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-calendar (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-calendar (30-calendar) days from the date of discharge from the facility or for sixty-calendar (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 no longer medically eligible; or

(4)   who no longer meet medical eligibility or cannot be located to complete the redetermination assessment, the area nurse or nurse designee, updates the system's medical eligibility end date and notifies the DHS State Plan Care Unit (SPCU) nurse of effective end date. The DHS SPCU nurse submits closure notification to the provider agency.

(h)   Termination of State Plan personal care services.

(1)   Personal care services may be discontinued when:

(A)   the member poses a threat to self or others as supported by professional documentation;

(B)   other members of the household or persons who routinely visit the household who, as supported by professional documentation or other credible documentation, pose a threat to the member or other household visitors;

(C)   the member or the other household members use threatening, intimidating, degrading, or sexually inappropriate language and/or innuendo or behavior towards service providers, either in the home or through other contact or communications; and efforts to correct such behavior were unsuccessful as supported by professional documentation or other credible documentation.

(D)   the member or family member fails to cooperate with Personal Care service delivery or to comply with Oklahoma Health Care Authority (OHCA) or DHS rules as supported by professional documentation;

(E)   the member's health or safety is at risk as supported by professional documentation;

(F)   additional services, either "formal" such as, paid by Sooner Care (Medicaid) or some other funding source or "informal" such as, unpaid are provided in the home eliminating the need for SoonerCare personal care services;

(G)   the individual's living environment poses a physical threat to self or others as supported by professional documentation where applicable, and measures to correct hazardous conditions or assist the person to move are unsuccessful or are not feasible; or

(H)   the member refuses to select and/or accept the services of a provider agency or personal care assistant (PCA) for ninety-consecutive (90-consecutive) days as supported by professional documentation.

(2)   For persons receiving personal care services, the personal care provider agency submits documentation with the recommendation to discontinue services to DHS. The DHS nurse reviews the documentation and submits it to the DHS area nurse for determination. The DHS nurse notifies the personal care provider agency or PCA and the local DHS county worker of the decision to terminate services. The member is sent an official closure notice informing him or her of appropriate member rights to appeal the decision to discontinue services.

[Source: 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 25, eff 9-18-97 (emergency); Amended at 15 Ok Reg 1554, eff 5-11-98; Amended at 17 Ok Reg 2410, eff 6-26-00; Amended at 20 Ok Reg 1958, eff 6-26-03; Amended at 24 Ok Reg 95, eff 8-2-06 (emergency); Amended at 24 Ok Reg 945, eff 5-11-07; Amended at 26 Ok Reg 549, eff 2-1-09 (emergency); Amended at 26 Ok Reg 2140, eff 6-25-09; Amended at 32 Ok Reg 1142, eff 8-27-15; Amended at 34 Ok Reg 726, eff 9-1-17; Amended at 36 Ok Reg 945, eff 9-1-19]