SECTION 317:35-17-26. Ethics of Care Committee

(a)   The ADvantage Program Ethics of Care Committee (EOCC) reviews members cases when the ADvantage, State Plan Personal Care programs or a provider contracted to provide these services determines that a member's identified needs cannot be met through the provision of the ADvantage program or State Plan Personal Care program and other formal or informal services are not in place or immediately available to meet the members health and safety needs. The EOCC is a core group of designated representatives from Oklahoma Department of Human Services (DHS) Aging Services and Oklahoma Health Care Authority staff and are experts in State Medicaid programs, specifically ADvantage waiver and State Plan Personal Care, and experienced in addressing member issues as it pertains to policy, program, and service delivery.

(b)   EOCC decisions are predicated upon four (4) guiding principles.

(1)   Sustainability of member services. The overarching concern of EOCC is to ensure that all efforts are made to sustain the member's services when possible. EOCC explores options and renders a decision that maintains member safety while averting the primary issue of concern before the EOCC. This is done while assuring member health and safety as outlined in Oklahoma Administrative Code (OAC) 317:35-17-3 (h) (1-7).

(2)   Cultural competence. EOCC considers the contextual details of the situation to promote needs and interests of ADvantage members and emphasizes understanding of the members culture and relevant circumstances.

(3)   Balance and reciprocity. This assures member health and safety is reliant upon the member's cooperation and that of the member's community network, or informal supports. EOCC evaluates the viability of the member's resources to sustain health and safety independent of Medicaid paid supports when making decisions.

(4)   Education and mitigation. EOCC uses decision-making processes for determining program appropriateness for cases that are problematic or controversial with respect to being able to meet member needs within program constraints. The decision-making process engages expertise from any area of program function relevant to the case in question when necessary. When the case submitted for review is deemed invalid or lacking sufficient merit for review, EOCC rescinds the review until the case meets the appropriate criteria for review.

(c)   EOCC reviews ADvantage and State Plan Personal Care cases, including but not limited to, when:

(1)   the member can no longer safely remain in the community;

(2)   the member shows a consistent pattern of non-compliance and non-cooperativeness that prevents delivery of the authorized person-centered service plan or care plan;

(3)   the provider's and/or DHS staff's safety cannot be assured due to the actions of the member, visit or another household member;

(4)   the services required to meet member needs are beyond the scope of defined waiver or State Plan Personal Care services;

(5)   the new ADvantage or State Plan Personal Care members meet financial and medical eligibility for the program, but require review for program appropriateness or community potential;

(6)   the previous dis-enrolled ADvantage or State Plan Personal Care members that request re-enrollment into the ADvantage or State Plan Personal Care programs;

(7)   the member scheduled for an administrative hearing in which the hearing officer requests EOCC review and input;

(8)   members under investigation or review by a federal authority; or

(9)   all cases in which administrative review and input are warranted.

(d)   ADvantage Consumer Directed Personal Assistance Service and Supports (CD-PASS) service option cases are reviewed for the:

(1)   circumstances under review are not addressed by CD-PASS requirements for member eligibility;

(2)   a case scenario is not otherwise covered by an established process;

(3)   established processes of the CD-PASS program do not allow for an adequate resolution to the issues; or

(4)   CD-PASS eligibility impacts ADvantage eligibility, such as:

(A)   eligibility is removed but that action may place the member at a greater risk; or

(B)   a member and/or their legal agent are removed from CD-PASS services due to allegations of fraudulent or illegal actions that may result in the member's loss of ADvantage eligibility.

(e)   EOCC review processes include:

(1)   ADvantage Administration (AA) Program Assistant Administrator for Member/Provider Relations department chairs the EOCC. He or she is responsible to appoint qualified representatives to the EOCC committee;

(2)   committee members, case representatives, or presenters are required to adhere to Health Insurance Portability and Accountability Act and DHS confidentiality standards and be discreet when reviewing and discussing cases under consideration of all records and information disclosed in carrying out the duties and activities of the committee;

(3)   all cases that meet the defined criteria for EOCC review are submitted to AA Member/Provider Relations or Escalated Issues teams for processing and presentation;

(4)   the Escalated Issues team formally requests a meeting for EOCC case review and develop a meeting agenda and provide EOCC members with relevant supporting documentation of EOCC review prior to the scheduled meeting;

(5)   a quorum (half plus one committee member) is present to make a decision or recommendation on any case presented to the EOCC;

(6)   designees are not substituted for EOCC members;

(7)   the EOCC Chair is notified in advance when it becomes necessary for other parties to be invited due to their expertise on the subject matter;

(8)   case presenters are dismissed after their presentations are complete and the EOCC proceeds to mitigate the case;

(9)   upon completion of the committee discussion, the EOCC Chair calls for a vote. A majority vote carries the motion. When a tie ensues the Escalated Issues team Program Manager casts the deciding vote;

(10)   a member determined by EOCC to be ineligible for ADvantage or Medicaid State Plan Personal Care program services is notified in writing by DHS of the determination and of his or her right to appeal the decision; and

(11)   EOCC maintains all meeting minutes, decisions, court hearings, and files generated by our Escalated Issues department pertaining to the member indefinitely.

[Source: Added at 35 Ok Reg 1497, eff 9-14-18]