SECTION 317:50-1-3. Medically Fragile Program overview

(a)   The Medically Fragile Waiver program is a Medicaid Home and Community Based Services Waiver used to finance non-institutional long-term care services for a targeted group of physically disabled adults when there is a reasonable expectation that the person's health, due to disease process or disability, would, without appropriate services, deteriorate and require skilled nursing facility or hospital level of care to arrest the deterioration. Medically Fragile Waiver program members must be SoonerCare eligible and must not reside in an institution; room and board licensed residential care facility. The number of members who may receive Medically Fragile Waiver services is limited.

(1)   To receive Medically Fragile Waiver services, individuals must meet the following criteria:

(A)   be nineteen (19) years of age or older;

(B)   have a chronic medical condition which results in prolonged dependency on medical care for which daily skilled intervention is necessary and is characterized by one or more of the following:

(i)   a life threatening condition characterized by reasonably frequent periods of acute exacerbation which requires frequent medical supervision and/or physician consultation and which, in the absence of such supervision or consultation, would require hospitalization;

(ii)   require frequent time consuming administration of specialized treatments which are medically necessary;

(iii)   be dependent on medical technology such that without the technology, a reasonable level of health could not be maintained.

(2)   In addition, the individual must meet the following criteria:

(A)   meet service eligibility criteria [see OAC 317:50-1-3(d)]; and

(B)   meet program eligibility criteria [see OAC 317:50-1-3(e)].

(b)   Home and Community Based Waiver Services are outside the scope of state plan Medicaid services. The Medicaid waiver allows the Oklahoma Health Care Authority to offer certain Home and Community Based services to an annually capped number of persons who are categorically needy (refer to Department of Human Services form 08AX001E, Schedule VIII. B. 1) and without such services would be institutionalized. Services provided through the Medically Fragile Waiver are approved based on medical necessity.

(c)   Services provided through the Medically Fragile Waiver are:

(1)   case management;

(2)   institutional transition case management;

(3)   respite;

(4)   environmental modifications;

(5)   specialized medical equipment and supplies;

(6)   physical therapy, occupational therapy, respiratory therapy, speech therapy or consultation;

(7)   advanced supportive/restorative assistance;

(8)   skilled nursing;

(9)   home delivered meals;

(10)   hospice care;

(11)   medically necessary prescription drugs within the limits of the waiver;

(12)   personal care;

(13)   personal emergency response system (PERS);

(14)   self-directed personal care, respite and advanced supportive/restorative assistance;

(15)   self-directed goods and services (SD-GS);

(16)   transitional case management; and

(17)   SoonerCare medical services within the scope of the state plan.

(d)   A service eligibility determination is made using the following criteria:

(1)   an open Medically Fragile Waiver Program waiver slot, as authorized by the waiver document approved by the Centers for Medicare and Medicaid Services (CMS), is available to assure federal participation in payment for services to the member. If it is determined that all Medically Fragile Waiver slots are filled, the member cannot be certified as eligible for Medically Fragile Waiver services and the member's name is placed on a waiting list for entry as an open slot becomes available. Medically Fragile Waiver slots and corresponding waiting lists, if necessary, are maintained.

(2)   the member is in the Medically Fragile Waiver targeted service group. The target group is an individual who is age nineteen (19) or older with a physical disability and may be technology dependent.

(3)   the individual does not pose a physical threat to self or others as supported by professional documentation.

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

(e)   The Medically Fragile Waiver program eligibility determination is made through the service plan approval process. The following criteria are used to make the determination that an individual is not eligible:

(1)   if the individual's needs as identified by Uniform Comprehensive Assessment Test assessment and other professional assessments cannot be met through Medically Fragile Waiver program services, SoonerCare state plan services and other formal or informal services. The State, as part of the waiver program approval authorization, assures CMS that each waiver member's health, safety, or welfare can be maintained in their home. If an individual's identified needs cannot be met through provision of Medically Fragile Waiver program or SoonerCare state plan services and other formal or informal services are not in place or immediately available to meet those needs, the individual's health, safety or welfare in their home cannot be assured.

(2)   if the individual poses a physical threat to self or others as supported by professional documentation.

(3)   if other members of the household or persons who routinely visit the household who, as supported by professional documentation, pose a threat of harm or injury to the individual or other household visitors.

(4)   if the individual's needs are being met, or do not require Medically Fragile Waiver services to be met, or if the individual would not require institutionalization if needs are not met.

(5)   if, after the service and care plan is developed, the risk to individual health and safety is not acceptable to the individual, or to the interdisciplinary service plan team, or to the OHCA.

(f)   Professional documentation is provided to support the recommendation for redetermination of program eligibility. The service providers continue providing services according to the service plan as provider safety permits until the member is removed from the Medically Fragile Waiver program. As a part of the procedures requesting redetermination of program eligibility, the OHCA will provide technical assistance to the provider for transitioning the member to other services.

(g)   Redetermination of program eligibility can be requested for the following reasons:

(1)   if the member fails to comply with the community service plan;

(2)   if the member's health and safety cannot be assured;

(3)   as deemed necessary by waiver review staff or the member's case manager.

(h)   Individuals determined ineligible for Medically Fragile Waiver program services are notified in writing of the determination and of his or her right to appeal the decision.

[Source: Added at 27 Ok Reg 2769, eff 8-1-10 (emergency); Added at 28 Ok Reg 1589, eff 6-25-11; Amended at 29 Ok Reg 1212, eff 6-25-12; Amended at 30 Ok Reg 1277, eff 7-1-13; Amended at 33 Ok Reg 924, eff 9-1-16; Amended at 35 Ok Reg 1511, eff 9-14-18]