SECTION 317:35-17-19. Closure or termination of ADvantage services

(a)   Voluntary closure of ADvantage services. When the member requests a lower level of care than ADvantage services, or agrees that ADvantage services are no longer needed to meet his or her needs, a medical level of care decision by the area nurse or nurse designee, is not needed. The closure request is completed and signed by the member and the ADvantage case manager and sent to the ADvantage Administration (AA) to be placed in the member's case record. The AA notifies the Oklahoma Department of Human Services (DHS) area nurse or area nurse designee of the voluntary closure and effective date of closure. When the member's written request for closure cannot be secured, the ADvantage case manager documents in the member's case record the reasons for the voluntary termination of services and alternatives for services.

(b)   Closure due to financial or medical ineligibility. The process for closure due to financial or medical ineligibility is described in this subsection.

(1)   Financial ineligibility. When the local DHS office determines a member does not meet financial eligibility criteria, the DHS office notifies the area nurse or area nurse designee who closes the member's authorization and notifies the member and AA of financial ineligibility by system-generated mail. The AA notifies the member's providers of the decision. A medical eligibility redetermination is not required when a financial ineligibility period does not exceed the medical certification period.

(2)   Medical ineligibility. When the DHS office is notified by the nurse or area nurse designee of a decision that the member is no longer medically eligible for ADvantage services, the DHS office notifies the member and AA of the decision. Refer to Oklahoma Administrative Code (OAC) 317:35-17-16 (d). The AA notifies the member's providers of the decision.

(c)   Closure due to other reasons. Refer to OAC 317:35-17-3(e) - (h).

(d)   Resumption of ADvantage services. When a member approved for ADvantage services is without services for less than ninety (90) calendar days and has a current medical and financial eligibility determination, services may be resumed using the previous authorized person-centered service plan. When a member requests to have his or her services restarted after ninety (90) calendar days, the member must request a new referral for services through the DHS county office or AA. When a member is determined eligible for ADvantage services and transistions from a hospital or a nursing facility to a community setting, an ADvantage case manager may provide Institution Transition case management services to assist the member to establish or re-establish him or herself safely in the home.

[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 3715, eff 5-28-98 (emergency); Amended at 16 Ok Reg 1438, eff 5-27-99; Amended at 17 Ok Reg 2410, eff 6-26-00; Amended at 20 Ok Reg 1958, eff 6-26-03; Amended at 21 Ok Reg 2252, eff 6-25-04; Amended at 29 Ok Reg 1172, eff 6-25-12; Amended at 35 Ok Reg 1497, eff 9-14-18]