SECTION 317:35-15-4. Determination of medical eligibility for Personal Care

(a)   Eligibility. The Oklahoma Department of Human Services (DHS) area nurse determines medical eligibility for personal care services based on the Uniform Comprehensive Assessment Tool (UCAT) Part III and the determination that the member has unmet care needs that require personal care services. Personal care services are initiated to support the regular care provided in the member's home. Personal care services are not intended to take the place of regular care and general maintenance tasks or meal preparation shared or done for one another by natural supports, such as spouses or other adults who live in the same household. Additionally, personal care services are not furnished when they principally benefit the family unit. To be eligible for personal care services, the individual must:

(1)   have adequate informal supports consisting of adult supervision that is present or available to contribute to care, or decision-making ability as documented on the UCAT Part III, to remain in his or her home without risk to his or her health, safety, and well-being, the individual:

(A)   must have the decision-making ability to respond appropriately to situations that jeopardize his or her health and safety or available supports that compensate for his or her lack of ability as documented on the UCAT Part III; or

(B)   who has his or her decision-making ability, but lacks the physical capacity to respond appropriately to situations that jeopardize health and safety and was informed by the DHS nurse of potential risks and consequences, may be eligible.

(2)   require a plan of care involving the planning and administration of services delivered under the supervision of professional personnel;

(3)   have a physical impairment or combination of physical and mental impairments as documented on the UCAT Part III. An individual who poses a threat to self or others as supported by professional documentation or other credible documentation may not be approved for Personal Care services. An individual who is actively psychotic or believed to be in danger of potential harm to self or others may not be approved for personal care services;

(4)   not have members of the household or persons who routinely visit the household who, as supported by professional documentation or other credible documentation, pose a threat of harm or injury to the individual or other household visitors;

(5)   lack the ability to meet personal care needs without additional supervision or assistance, or to communicate needs to others; and

(6)   require assistance, not of a technical nature, to prevent or minimize physical health regression and deterioration.

(b)   Definitions. The following words and terms, when used in this subsection, shall have the following meaning, unless the context clearly indicates otherwise:

(1)   "Activities of Daily Living" (ADL) means activities of daily living are activities that reflect the member's ability to perform self-care tasks essential for sustaining health and safety, such as:

(A)   bathing;

(B)   eating;

(C)   dressing;

(D)   grooming;

(E)   transferring includes activities such as getting in and out of a tub or bed to chair;

(F)   mobility;

(G)   toileting; and

(H)   bowel/bladder control.

(2)   "ADLs score of three or greater" means the member cannot do at least one ADL at all or needs some help with two or more ADLs.

(3)   "Consumer support very low need"means the member's UCAT Part III Consumer Support score is zero (0) which indicates, in the UCAT Part III assessor's clinical judgment, the formal and informal sources are sufficient for present level of member need in most functional areas.

(4)   "Consumer support low need" means the member's UCAT Part III Consumer Support score is five (5) which indicates, in the UCAT Part III assessor's clinical judgment, the support from formal and informal sources are nearly sufficient for present level of member need in most functional areas. The member, family, or informal supports are meeting most needs typically expected of family or household members to share or do for one another, such as general household maintenance. There is little risk of institutional placement with loss of current supports.

(5)   "Consumer support moderate need" means the UCAT Part III Consumer score is fifteen (15) which indicates, in the UCAT Part III assessor's clinical judgment, the formal and informal support is available, but overall, it is inadequate, changing, fragile, or otherwise problematic. The member requires additional assistance that usually includes personal care assistance with one or more ADLs not available through Medicare, the Veterans Administration, or other federal entitlement programs. Support provided by informal caregivers is of questionable reliability due to one (1) or more of the following:

(A)   care or support is required continuously with no relief or backup available;

(B)   informal support lacks continuity due to conflicting responsibilities such as work or child care;

(C)   care or support is provided by persons with advanced age or disability; or

(D)   institutional placement can reasonably be expected with any loss of existing support.

(6)   "Consumer support high need" means the member's UCAT Part III Consumer score is twenty-five (25) which indicates, in the UCAT Part III assessor's clinical judgment, the formal and informal supports are not sufficient as there is very little or no support available to meet a high degree of member need.

(7)   "Community services worker" means any non-licensed health professional employed by or under contract with a community services provider who provides, for compensation or as a volunteer, health-related services, training, or supportive assistance to frail elderly, disabled person(s), or person(s) with developmental disabilities.

(8)   "Community Services Worker Registry" means a registry established by the DHS, per Section (§) 1025.1 of Title 56 of the Oklahoma Statutes (O.S.) to list community services workers against whom a final investigative finding of abuse, neglect, or exploitation, per 43A O.S. § 10-103, involving a frail elderly, disabled person(s), or person(s) with developmental disabilities was made by DHS or an administrative law judge; and amended in 2002, to include the listing of SoonerCare (Medicaid) personal care assistants (PCAs) providing personal care services.

(9)   "Instrumental activities of daily living (IADL)" means those activities that reflect the member's ability to perform household chores and tasks within the community essential for sustaining health and safety, such as:

(A)   shopping;

(B)   cooking;

(C)   cleaning;

(D)   managing money;

(E)   using a phone;

(F)   doing laundry;

(G)   taking medication; and

(H)   accessing transportation.

(10)   "IADLs score is at least six (6)" means the member needs some help with at least three (3) IADLs or cannot do two (2) IADLs at all.

(11)   "IADLs score of eight (8) or greater" means the member needs some help with at least four (4) IADLs or the member cannot do two (2) IADLs at all and needs some help with one (1) or more other IADLs.

(12)   "MSQ" means the mental status questionnaire.

(13)   "MSQ moderate risk range" means a total weighted-score of seven (7) to eleven (11) that indicates an orientation-memory-concentration impairment or memory impairment.

(14)   "Nutrition moderate risk" means the total weighted UCAT Part III Nutrition score is eight (8) or more that indicates poor appetite or weight loss combined with special diet requirements, medications, or difficulties in eating.

(15)   "Social resources score is eight (8) or more" means the member lives alone or has no informal support when he or she is sick, needs assistance, or has little or no contact with others.

(c)   Medical eligibility minimum criteria for personal care. The medical eligibility minimum criteria for personal care are the minimum UCAT Part III score criteria that a member must meet for medical eligibility for personal care and are:

(1)   ADLs score is five (5) or greater; or IADLs score of eight (8) or greater; or Nutrition score is eight (8) or greater; or the MSQ score is seven (7) or greater; or the ADLs score is three (3) and IADLs score is at least six (6); and

(2)   Consumer Support is fifteen (15) or more; or Consumer Support score is five (5) and the Social Resources score is eight or more.

(d)   Medical eligibility determination. Medical eligibility for personal care is determined by the DHS. The medical decision for personal care is made by the DHS area nurse utilizing the UCAT Part III.

(1)   Categorical relationship must be established for determination of eligibility for personal care. When categorical relationship to Aid to the Disabled was not established but there is an extremely emergent need for personal care, and current medical information is not available, the local office authorizes a medical examination. When authorization is necessary, the county director issues Form 08MA016E, Authorization for Examination, and Form 08MA02E, Report of Physician's Examination, to a licensed medical or osteopathic health care professional, refer to Oklahoma Administrative Code (OAC) 317:30-5-1. The licensed health care professional cannot be in a medical facility internship, residency, or fellowship program or in the full time employment of the Veterans Administration, United States Public Health Service, or other agency. The DHS county worker submits the information to the Level of Care Evaluation Unit (LOCEU) to request a determination of eligibility for categorical relationship. LOCEU renders a decision on the categorical relationship using the Social Security Administration (SSA) definition. A follow-up is required by the DHS county worker with (SSA) to ensure the SSA disability decision is also the LOCEU decision.

(2)   Approved contract agencies or the ADvantage Administration (AA) may complete UCAT Part I for intake and screening and forward the form to the county office.

(3)   Upon receipt of the referral, DHS county staff may initiate the UCAT, Part I.

(4)   The DHS nurse is responsible for completing the UCAT Part III assessment visit within ten-business (10-business) days of the personal care referral for the applicant who is SoonerCare eligible at the time of the request. The DHS nurse completes the assessment visit within twenty-business (20-business) days of the referral for the applicant not determined SoonerCare eligible at the time of the request. When the UCAT Part I indicates the request is from an individual who resides at home and an immediate response is required to ensure the health and safety of the person, emergency situation, or to avoid institutional placement, the UCAT Part III assessment visit has top-scheduling priority.

(5)   During the assessment visit, the DHS nurse completes the UCAT Part III and reviews rights to privacy, fair hearing, provider choice, and the pre-service acknowledgement agreement with the member. The DHS nurse informs the applicant of medical eligibility criteria and provides information about DHS long-term care service options. The DHS nurse documents if the member wants to be considered for nursing facility level of care services or if the member is applying for a specific service program on UCAT Part III. When, based on the information obtained during the assessment, the DHS nurse determines if the member may be at risk for health and safety, an immediate referral is made to Adult Protective Services (APS) or Child Protective Services, as applicable. The referral is documented on the UCAT Part III.

(A)   When the applicant's needs cannot be met by personal care services alone, the DHS nurse informs the applicant of the other community long-term care service options. The DHS nurse assists the applicant in accessing service options selected by the applicant in addition to, or in place of, Personal Care services.

(B)   When multiple household members are applying for SoonerCare personal care services, the UCAT Part III assessment is done for all the household members at the same time.

(C)   The DHS nurse informs the applicant of the qualified agencies in his or her local area that provide services and obtains the applicant's primary and secondary choice of agencies. When the applicant or family declines to choose a primary personal care service agency, the DHS nurse selects an agency from a list of all available agencies, using a round-robin system. The DHS nurse documents the name of the selected personal care provider agency.

(6)   The DHS nurse completes the UCAT Part III and sends it to the DHS area nurse for medical eligibility determination. Personal care service eligibility is established on the date medical eligibility is approved and financial eligibility is established. This date serves as the certification date for services to be initiated.

(A)   When the length of time from the initial assessment to the date of service eligibility determination exceeds ninety-calendar (90-calendar) days, a new UCAT Part III and assessment visit is required.

(B)   The DHS area nurse assigns a medical certification period of not more than thirty-six (36) months for persons eighteen (18) years of age and older or not more than twelve (12) months for persons younger than eighteen (18) years of age. The service plan period under the Service Authorization Model (SAM) is for a period of twelve (12) months and is provided by the DHS nurse.

(7)   The DHS area nurse notifies the DHS county worker via Electronic Data Entry and Retrieval System (ELDERS) of the personal care certification. The authorization line is open via automation from ELDERS.

(8)   Upon establishment of personal care certification, the DHS nurse contacts the member's preferred provider agency, or when necessary, the secondary provider agency or the provider agency selected by the round robin system. Within one-business (1-business) day of provider agency acceptance, the DHS nurse forwards the referral information to the provider agency for SAM plan development. Refer to OAC 317:35-15-8(a).

(9)   Following the SAM packet development by the provider agency, and within three-business (3-business) days of receipt of the packet from the provider agency, the DHS nurse reviews the documentation to ensure agreement with the plan. Once agreement is established, the packet is authorized by the designee or submitted to the area nurse for review.

(10)   Within ten-business (10-business) days of receipt of the SAM case from the DHS nurse, the DHS area nurse authorizes or denies the SAM units. If the SAM case fails to meet standards for authorization, the case is returned to the DHS nurse for further justification.

(11)   Within one-business (1-business) day of knowledge of the authorization, the DHS nurse forwards the service plan authorization to the provider agency.

[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 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 21 Ok Reg 2252, eff 6-25-04; 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]