SECTION 317:35-18-5. Eligibility criteria

(a)   To be eligible for participation in Programs of All-Inclusive Care for the Elderly (PACE), the applicant must:

(1)   be age fifty-five (55) years or older;

(2)   live in a PACE service area;

(3)   be determined by the state to meet nursing facility level of care; and

(4)   be determined by the PACE interdisciplinary team (IDT) as able to be safely served in the community at the time of enrollment. If the PACE provider denies enrollment because the IDT determines that the applicant cannot be served safely in the community, the PACE provider must:

(A)   notify the applicant in writing of the reason for the denial;

(B)   refer the applicant to alternative services as appropriate;

(C)   maintain supporting documentation for the denial and notify the Centers for Medicare and Medicaid Services and the Oklahoma Health Care Authority (OHCA) of the denial and make the supporting documentation available for review; and

(D)   advise the applicant orally and in writing of the grievance and appeals process.

(b)   To be eligible for SoonerCare capitated payments, the individual must:

(1)   meet categorical relationship for the aged, blind, or disabled [refer to Oklahoma Administrative Code (OAC) 317:35-5-4];

(2)   be eligible for Title XIX services if institutionalized as determined by the Oklahoma Department of Human Services (DHS);

(3)   be eligible for SoonerCare State Plan services;

(4)   meet the same financial eligibility criteria as set forth for the SoonerCare ADvantage program per OAC 317:35-17-10 and 317:30-17-11; and

(5)   meet appropriate medical eligibility criteria.

(c)   The nurse designee makes the medical determination utilizing professional judgment, the Uniform Comprehensive Assessment Tool (UCAT) Part I, Part III, and other available medical information.

(1)   When PACE services are requested:

(A)   The PACE nurse or DHS nurse is responsible for completing the UCAT assessment.

(B)   The PACE intake staff is responsible for aiding the PACE enrollee in contacting DHS to initiate the financial eligibility application process.

(2)   The nurse completes the UCAT, Part III visit with the PACE enrollee, in the participant's home, within ten (10) days of receipt of the referral for PACE services.

(3)   The nurse sends the UCAT, Part III to the designated OHCA nurse staff member for review and level of care determination.

(4)   A new medical level of care determination may be required when a member requests any of the following changes in service programs:

(A)   from PACE to ADvantage;

(B)   from PACE to State Plan Personal Care Services;

(C)   from Nursing Facility to PACE;

(D)   from ADvantage to PACE if previous UCAT was completed more than six (6) months prior to member requesting PACE enrollment; or

(E)   from PACE site to PACE site.

(d)   To obtain and maintain eligibility, the individual must agree to accept the PACE providers and its contractors as the individual's only service provider. The individual may be held financially liable for services received without prior authorization except for emergency medical care.

[Source: Added at 23 Ok Reg 2583, eff 6-25-06; Amended at 29 Ok Reg 1189, eff 6-25-12; Amended at 31 Ok Reg 1748, eff 9-12-14; Amended at 33 Ok Reg 911, eff 9-1-16; Amended at 36 Ok Reg 956, eff 9-1-19]