SECTION 340:105-7-2. Eligibility for adult day services

(a)   Application process.

(1)   An application for adult day services is initiated by a request from an adult wishing to participate, a person responsible for the care of the adult, or by a referral from an adult day services vendor. The application is documented on Form 02AS003E, Adult Day Services Referral/Application.

(2)   Applicants for adult day services are referred to the ADvantage Waiver or the Developmental Disabilities Services Division (DDSD) Home and Community-Based Services (HCBS) Waiver, as appropriate. Adult day services may be received while the application for waivered services is pending.

(3)   All adult day services participants must be determined ineligible for either the ADvantage Waiver or the DDSD HCBS Waiver or be placed on the DDSD waiting list.

(A)   If the participant is not determined ineligible in four months, the participant may not continue in Oklahoma Department of Human Services (OKDHS) funded adult day services. The authorization is closed and services are terminated.

(B)   An exception or extension of the four months rule must be requested.

(4)   The service opening date is no earlier than the date on Form 02AS003E or the date of the oral request. If the participant does not sign Form 02AS003E at the time of request, a staff person completes the form and explains on the signature line why the participant did not sign, such as an oral request.

(A)   If the services are court-ordered and there is no Form 08AP001E, Adult Protective Services Referral, the service opening date is the date of the court order.

(B)   If the day services facility makes the referral by sending Form 02AS003E, the service opening date is the date the form is stamped "received" in the county office.

(5)   An application must be processed within 30 days for public assistance cases and 45 days for non-public assistance cases. The application is:

(A)   certified or approved when a participant is determined eligible;

(B)   denied when a participant is determined ineligible; or

(C)   canceled when a participant requests cancellation prior to other disposition.

(6)   In determining eligibility for adult day services, the participant must:

(A)   receive services in a facility that holds a valid contract with OKDHS for provision of adult day services; and

(B)   meet need, age, and income requirements.

(b)   Need for adult day services. Adult day services are appropriate for persons who are physically or mentally unable to function totally independently but do not require 24-hour care.

(1)   To qualify for adult day services, one of the conditions in (A) and (B) of this paragraph must be met.

(A)   Adult day services provide respite or time needed to maintain employment for an adult's primary caregiver.

(B)   Adult day services provide beneficial socialization and access to needed therapy for a functionally impaired adult.

(2)   If the participant is receiving state-funded 24-hour care, adult day services are not approved.

(c)   Age. Adult day services are available to impaired adults age 60 years and older. An age waiver may be requested, and is granted by Aging Services Division (ASD) for a person younger than 60 if one of the conditions in (1) and (2) of this paragraph is met.

(1)   The adult is suffering from Alzheimer's disease, any other form of dementia, or another degenerative condition, either physical or mental.

(2)   The adult has recently sustained a stroke, fracture, paralysis, or other incapacitating condition and the services offered in an adult day services program aid the adult in maintaining or returning to as much of an independent lifestyle as possible, avoiding institutionalization.

(d)   Income. Sources of income considered, verification, and computation of income for the adult day services program are described in this subsection. Co-payment and maximum allowable income are shown on OKDHS Appendix M-105, Eligibility Schedule/Rates for Adult Day Services. OKDHS Appendix M-105 reflects the sliding fee scale based upon the United States Bureau of Census, National Poverty Guidelines, as printed in the Federal Register. The schedule is subject to change.

(1)   Predetermined eligible. Persons are predetermined eligible based on receipt of Public Assistance, Supplemental Security Income (SSI), or Refugee Assistance. If services are requested by Adult Protective Services (APS), the participant is universally approved for 60 days only without regard to income. For APS participants, no co-payment is considered during the 60 calendar days.

(2)   Income eligible. Income eligibility determination is based upon the amount of the family's gross income and family's size. Family income includes income from predetermined eligible members.

(A)   Anticipated income is never included in determining eligibility until it is available to and under the control of the participant.

(B)   Income is computed on a monthly basis. If income is received every two weeks, the weekly rate is determined and multiplied by 4.3 to compute the monthly income. When income is received twice a month, for example, 1st and 15th, it is multiplied by two.

(C)   Any income that is received regularly, but in amounts that vary greatly, or income received irregularly is averaged over a six-month period. Examples are overtime pay, sporadic second jobs, irregular child support, and other occasional changes in the monthly gross child support or other monthly gross income.

(D)   When one or both persons of a married couple is in adult day services, the total gross income of both is considered and eligibility is computed based on one half of the total income.

(3)   Determination of co-payments for persons not predetermined eligible. In determining the co-payment for persons not predetermined eligible, the guidelines are:

(A)   married couple, one spouse in adult day services, the total gross income of both spouses is considered, with the co-payment computed on one half of the total income;

(B)   married couple, both in adult day services, the total gross income is divided equally between the two, with the co-payment for each based on the computed individual amount of income; or

(C)   single person in adult day services, only the total gross income of that person is considered.

(4)   Sources of income considered. The sources of income considered in determining monthly gross income are:

(A)   wages, such as total money earnings received for work performed as an employee, including armed forces pay, commissions, tips, piece-rate payments, on-the-job training programs, cash bonuses, bonds, pensions, union dues, credit union payments, garnishments, and similar purposes. Tips are not considered part of the wages for Temporary Assistance for Needy Families (TANF) recipients who are participating in the Work Supplementation Program;

(B)   net income from self-employment, farm and non-farm, determined by taking 50 percent of the gross income. When a participant:

(i)   rents a house to someone else, the net income amount considered is 50 percent of the rent. The other 50 percent is allowed for expenses;

(ii)   rents a room in his or her house to someone else, the net income amount considered is 75 percent of the rent; and

(iii)   provides room and board in his or her home, the net income amount considered is 50 percent of the gross amount charged;

(C)   pensions, SSI, survivors' benefits, and Social Security Administration permanent disability insurance, prior to deductions for medical insurance, and Railroad Retirement Insurance;

(D)   dividends, interest, and income from estates, trusts, and mineral rights. If this income varies or is received irregularly, it is averaged over six months;

(E)   pensions and annuities or retirement benefits paid to a retired person or his or her survivors by a former employer or by a union, either directly or through an insurance company, and periodic receipts from annuities or insurance;

(F)   unemployment compensation received from government unemployment insurance agencies or private companies during periods of unemployment and any strike benefits received from union funds;

(G)   workers' compensation received periodically from private or public insurance companies for injuries incurred at work. The cost of this insurance must have been paid by the employer and not by the participant;

(H)   alimony;

(I)   child support;

(J)   veterans' compensations and pensions paid periodically by Veterans Affairs to disabled members of the armed forces or to survivors of deceased veterans, as subsistence allowances paid to veterans for veterans' education and on-the-job training, and to ex-servicemen as GI insurance premiums called refunds;

(K)   contributions in the form of money received regularly from anyone; and

(L)   income of minor children. If the adult in an adult day services program has minor children living in the same home, the children's income is considered.

(5)   Sources of income not considered. The sources of income not considered monthly gross income are:

(A)   per capita payments to or funds held in trust for any individual in satisfaction of a judgment of the Indian Claims Commission of the Court of Claims;

(B)   payments made pursuant to the Alaska Native Claims Settlement Act, to the extent that such payments are exempt from taxation under Section 21(a) of the Act;

(C)   money received from sale of a resource, such as stocks, bonds, land, house, or car. If the person is in the business of selling such property, the net proceeds are counted as income from self-employment;

(D)   withdrawals of bank deposits;

(E)   tax refunds, including the Earned Income Credit Advance payment which is received monthly;

(F)   gifts or money received occasionally, such as at birthdays, anniversaries, and Christmas;

(G)   lump sum inheritances, insurance payments, or one-time lump sum payments;

(H)   capital gain;

(I)   the value of the food benefit allotment under the Food Stamp Act of 1977, as amended;

(J)   any payment received under the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970;

(K)   loans and grants obtained and used under conditions that preclude their use for current living costs;

(L)   money received as reimbursement for expenses because of participation in a component of the TANF Work Program;

(M)   home produce utilized for household consumption; and

(N)   the income of adult children or other relatives residing in the same home as the adult day services participant.

(e)   Resources. Resources are not considered in determining eligibility for adult day services.

(f)   Notification. A ten-day notice is required for any adverse action. Notification to the participant is required and is computer-generated when:

(1)   a decision regarding initial eligibility or continued eligibility is made;

(2)   there is a change in the participant's income or co-payment; and

(3)   the participant is no longer eligible or requests termination of adult day services.

[Source: Amended at 9 Ok Reg 1727, eff 4-20-92 (emergency); Amended at 9 Ok Reg 2917, eff 7-13-92; Amended at 15 Ok Reg 1316, eff 3-1-98 (emergency); Amended at 16 Ok Reg 1058, eff 4-26-99; Amended at 16 Ok Reg 3383, eff 5-11-99 (emergency); Amended at 17 Ok Reg 1320, eff 5-11-00; Amended at 18 Ok Reg 2138, eff 6-11-01; Amended at 23 Ok Reg 393, eff 11-8-05 (emergency); Amended at 23 Ok Reg 1062, eff 7-15-06; Amended at 24 Ok Reg 1325, eff 6-1-07]