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Part       HABILITATION SERVICES

317:30⊂chapter=5∂=51--480.Home and Community-Based Services for persons with an intellectual disability or certain persons with related conditions

[Revised 06-25-12]
The Oklahoma Health Care Authority (OHCA) administers Home and Community-Based Services (HCBS) Waivers for persons with intellectual disabilities or certain persons with related conditions that are operated by the Oklahoma Department of Human Services Developmental Disabilities Services Division (DDSD). Each waiver allows Medicaid compensable services provided to persons who are:
(1) medically and financially eligible; and
(2) not covered through the OHCA's SoonerCare program.


 

317:30⊂chapter=5∂=51--481.Coverage
[Revised 5-11-07]
All habilitation services will be included in the member's Individual Plan (IP). Arrangements for care under this program must be made with the member's case manager.

317:30⊂chapter=5∂=51--482.Description of services

[Revised 09-14-18]
   Habilitation services include the services identified in (1) through (15) of this Section. Habilitation services providers must have an applicable agreement with the Oklahoma Health Care Authority (OHCA) to provide Developmental Disabilities Services (DDS) Home and Community-Based Services (HCBS).

(1) Dental services.  Dental services are provided per Oklahoma Administrative Code (OAC) 317:40-5-112.

(A) Minimum qualifications.  Dental services providers must have non-restrictive licensure by the Oklahoma State Board of Dentistry to practice dentistry in Oklahoma.

(B) Description of services.  Dental services include services for maintenance or improvement of dental health as well as relief of pain and infection. These services may include:

(i) an oral examination;

(ii) bite-wing X-rays;

(iii) dental cleaning;

(iv) topical-fluoride treatment;

(v) development of a sequenced treatment plan that prioritizes:

(I) elimination of pain;

(II) adequate oral hygiene; and

(III) restoration or an improved ability to chew;

(vi) routine training of member or primary caregiver regarding oral hygiene; and

(vii) preventive, restorative, replacement, and repair services to achieve or restore functionality provided after appropriate review when applicable, per OAC 317:40-5-112.

(C) Coverage limitations.  Coverage of dental services is specified in the member's Individual Plan (IP) in accordance with applicable Waiver limits. Dental services are not authorized when recommended for cosmetic purposes.

(2) Nutrition services.  Nutrition Services are provided per OAC 317:40-5-102.

(3) Occupational therapy services.

(A) Minimum qualifications.  Occupational therapists and occupational therapy assistants must have current, non-restrictive licensure by the Oklahoma Board of Medical Licensure and Supervision. Occupational therapy assistants must be employed by occupational therapists.

(B) Description of services.  Occupational therapy services include evaluation, treatment, and consultation in leisure management, daily living skills, sensory motor, perceptual motor, and mealtime assistance. Occupational therapy services may include the use of occupational therapy assistants, within the limits of the occupational therapist's practice.

(i) Services are:

(I) intended to help the member achieve greater independence to reside and participate in the community; and

(II) rendered in any community setting as specified in the member's IP. The IP must include a practitioner's prescription.

(ii) For purposes of this Section, a practitioner is defined as medical and osteopathic physicians, physician assistants, and other licensed health care professionals with prescriptive authority to order occupational therapy services in accordance with the rules and regulations governing the SoonerCare program.

(iii) The provision of services includes a written report or record documentation in the member's record, as required.

(C) Coverage limitations.  Payment is made for compensable services to the individual occupational therapist for direct services or for services provided by a qualified occupational therapist assistant, within the occupational therapist's employment. Payment is made in 15-minute units, with a limit of 480 units per Plan of Care year. Payment is not allowed solely for written reports or record documentation.

(4) Physical therapy services.

(A) Minimum qualifications.  Physical therapists and physical therapist assistants must have current, non-restrictive licensure with the Oklahoma Board of Medical Licensure and Supervision. The physical therapist must employ the physical therapist assistant.

(B) Description of services.  Physical therapy services include evaluation, treatment, and consultation in locomotion or mobility and skeletal and muscular conditioning to maximize the member's mobility and skeletal/muscular well-being. Physical therapy services may include the use of physical therapist assistants, within the limits of the physical therapist's practice.

(i) Services are intended to help the member achieve greater independence to reside and participate in the community. Services are provided in any community setting as specified in the member's IP. The IP must include a practitioner's prescription.

(ii) For purposes of this Section, a practitioner is defined as a licensed medical and osteopathic physicians, and physician assistants in accordance with the rules and regulations covering the OHCA SoonerCare program.

(iii) The provision of services includes a written report or record documentation in the member's record, as required.

(C) Coverage limitations.  Payment is made for compensable services to individual physical therapists for direct services or for services provided by a qualified physical therapist assistant within the physical therapist's employment. Payment is made in 15-minute units with a limit of 480 units per Plan of Care year. Payment is not allowed solely for written reports or record documentation.

(5) Psychological services.

(A) Minimum qualifications.  Qualification as a provider of psychological services requires current, non-restrictive licensure as a psychologist by the Oklahoma State Board of Examiners of Psychologists or licensing board in the state in which service is provided. Psychological technicians who have completed all board certification and training requirements may provide services under a licensed psychologist's supervision.

(B) Description of services.  Psychological services include evaluation, psychotherapy, consultation, and behavioral treatment. Service is provided in any community setting as specified in the member's IP. The provider must develop, implement, evaluate and revise the Protective Intervention Protocol (PIP) corresponding to the relevant outcomes identified in the member's IP.

(i) Services are:

(I) intended to maximize a member's psychological and behavioral well-being; and

(II) provided in individual and group formats, with a six-person maximum.

(ii) Approval of services is based upon assessed needs per OAC 340:100-5-51.

(C) Coverage limitations.

(i) Payment is made in 15 minute units. A minimum of 15 minutes for each individual and group encounter is required.

(ii) Psychological services are authorized for a period, not to exceed twelve (12) months.

(I) Initial authorization must not exceed 192 units, 48 hours of service.

(II) Authorizations may not exceed 288 units per plan of care year unless an exception is made by the DDS director of Behavior Support Services or his or her designee.

(III) No more than 12 hours of services, 48 units, may be billed for PIP preparation. Any clinical document must be prepared within sixty (60) calendar days of the request. Further, if the document is not prepared, payments are suspended until the requested document is provided.

(IV) When revising a PIP to accommodate recommendations of a required committee review, the provider may bill for only one revision. The time for preparing the revision must be clearly documented and must not exceed four hours.

(6) Psychiatric services.

(A) Minimum qualifications.  Qualification as a psychiatric services provider requires a current, non-restrictive license to practice medicine in Oklahoma. Certification by the American Board of Psychiatry and Neurology or satisfactory completion of an approved residency program in psychiatry is required.

(B) Description of services.  Psychiatric services include outpatient evaluation, psychotherapy, medication and prescription management and consultation, and are provided to eligible members. Services are provided in community setting specified in the member's IP.

(i) Services are intended to contribute to the member's psychological well-being.

(ii) A minimum of 30 minutes for encounter and record documentation is required.

(C) Coverage limitations.  A unit is 30 minutes, with a limit of 200 units, per Plan of Care year.

(7) Speech/language services.

(A) Minimum qualifications.  Qualification as a speech and/or language services provider requires current, non-restrictive licensure as a speech and/or language pathologist by the Oklahoma Board of Examiners for Speech Pathology and Audiology.

(B) Description of services.  Speech therapy includes evaluation, treatment, and consultation in communication and oral motor and/or feeding activities provided to eligible members. Services are intended to maximize the member's community living skills and may be provided in the community setting specified in the member's IP. The IP must include a practitioner's prescription.

(i) For purposes of this Section, practitioners are defined as licensed medical and osteopathic physicians, physician assistants, and other licensed professionals with prescriptive authority to order speech and/or language services in accordance with rules and regulations covering the OHCA SoonerCare program.

(ii) A minimum of 15 minutes for encounter and record documentation is required.

(C) Coverage limitations.  A unit is 15 minutes, with a limit of 288 units, per Plan of Care year.

(8) Habilitation training specialist (HTS) services.

(A) Minimum qualifications.  Providers must complete the Oklahoma Department of Human Services (DHS) DDS-sanctioned training curriculum. Residential habilitation providers:

(i) are at least 18 years of age;

(ii) are specifically trained to meet members' unique needs;

(iii) were not convicted of, pled guilty to, or pled nolo contendere to misdemeanor assault and battery, or a felony, per Section 1025.2 of Title 56 of the Oklahoma Statutes (56 O.S. ' 1025.2); unless a waiver is granted, per 56 O.S. ' 1025.2; and

(iv) receive supervision and oversight from contracted-agency staff with a minimum of four years of any combination of college-level education or full-time equivalent experience in serving persons with disabilities.

(B) Description of services.  HTS services include services to support the member's self-care, daily living, and adaptive and leisure skills needed to reside successfully in the community. Services are provided in community-based settings in a manner that contributes to the member's independence, self-sufficiency, community inclusion, and well-being.

(i) Payment is not made for:

(I) routine care and supervision normally provided by family; or

(II) services furnished to a member by a person who is legally responsible per OAC 340:100-3-33.2.

(ii) Family members who provide HTS services must meet the same standards as providers who are unrelated to the member. HTS staff residing in the same household as the member may not provide services in excess of 40 hours per week. Members requiring more than 40 hours per week of HTS services, must use staff members, who do not reside in the household and are employed by the member's chosen provider agency to deliver the balance of necessary support staff hours. Exceptions may be authorized, when needed, for members who receive services through the Homeward Bound Waiver.

(iii) Payment does not include room and board or maintenance, upkeep, or improvement of the member's or family's residence.

(iv) For members who also receive intensive personal supports (IPS), the member's IP must clearly specify the role of the HTS and person providing IPS to ensure there is no duplication of services.

(v) Review and approval by the DDS plan of care reviewer is required.

(vi) Pre-authorized HTS services accomplish the same objectives as other HTS services, but are limited to situations where the HTS provider is unable to obtain required professional and administrative oversight from an OHCA-approved oversight agency. For pre-authorized HTS services, the service:

(I) provider receives DDS area staff oversight; and

(II) must be pre-approved by the DDS director or his or her designee.

(C) Coverage limitations.  HTS services are authorized per OAC 317:40-5-110, 317:40-5-111, 317:40-7-13, and 340:100-3-33.1.

(i) A unit is 15 minutes.

(ii) Individual HTS services providers are limited to a maximum of 40 hours per week regardless of the number of members served.

(iii) More than one HTS may provide care to a member on the same day.

(iv) Payment cannot be made for services provided by two or more HTSs to the same member during the same hours of a day.

(v) A HTS may receive reimbursement for providing services to only one member at any given time. This does not preclude services from being provided in a group setting where services are shared among members of the group.

(vi) HTS providers may not perform any job duties associated with other employment including on-call duties, at the same time they are providing HTS services.

(9) Self Directed HTS (SD HTS).  SD HTS are provided per OAC 317:40-9-1.

(10) Self Directed Goods and Services (SD GS).  SD GS are provided per OAC 317:40-9-1.

(11) Audiology services.

(A) Minimum qualifications.  Audiologists must have licensure as an audiologist by the Oklahoma Board of Examiners for Speech Pathology and Audiology.

(B) Description of services.  Audiology services include individual evaluation, treatment, and consultation in hearing to eligible members. Services are intended to maximize the member's auditory receptive abilities. The member's IP must include a practitioner's prescription.

(i) For purposes of this Section, practitioners are defined as licensed medical and osteopathic physicians, and physician assistants in accordance with rules and regulations covering the OHCA SoonerCare program.

(ii) A minimum of 15 minutes for encounter and record documentation is required.

 (C) Coverage limitations.  Audiology services are provided in accordance with the member's IP.

(12) Prevocational services.

(A) Minimum qualifications.  Prevocational services providers:

(i) are at least 18 years of age;

(ii) complete the DHS DDS-sanctioned training curriculum;

(iii) were not convicted of, pled guilty to, or pled nolo contendere to misdemeanor assault and battery, or a felony per 56 O.S. ' 1025.2, unless a waiver is granted per 56 O.S. ' 1025.2; and

(iv) receive supervision and oversight by a person with a minimum of four years of any combination of college-level education or full-time equivalent experience in serving persons with disabilities.

(B) Description of services.  Prevocational services are not available to persons who can be served under a program funded per Section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (IDEA) per Section 1401 et seq. of Title 20 of the United States Code.

(i) Prevocational services are learning and work experiences where the individual can develop general, non-job, task-specific strengths that contribute to employability in paid employment in integrated community settings.

(ii) Activities include teaching concepts, such as communicating effectively with supervisors, co-workers, and customers, attendance, task completion, problem solving, and safety. These activities are associated with building skills necessary to perform work.

(iii) Pre-vocational services are delivered for the purpose of furthering habilitation goals that lead to greater opportunities for competitive, integrated employment. All prevocational services are reflected in the member's IP. Documentation must be maintained in the record of each member receiving this service, noting the service is not otherwise available through a program funded under the Rehabilitation Act of 1973 or IDEA.

(iv) Services include:

(I) center-based prevocational services, per OAC 317:40-7-6;

(II) community-based prevocational services per, OAC 317:40-7-5;

(III) enhanced community-based prevocational services per, OAC 317:40-7-12; and

(IV) supplemental supports, as specified in OAC 317:40-7-13.

(C) Coverage limitations.  A unit of center-based or community-based prevocational services is one hour and payment is based on the number of hours the member participates in the service. All prevocational services and supported-employment services combined may not exceed $27,000, per Plan of Care year. The services that may not be provided to the same member at the same time as prevocational services are:

(i) HTS;

(ii) Intensive Personal Supports;

(iii) Adult Day Services;

(iv) Daily Living Supports;

(v) Homemaker; or

(vi) therapy services, such as occupational therapy; physical therapy; nutrition, speech, or psychological services; family counseling; or family training, except to allow the therapist to assess the individual's needs at the workplace or to provide staff training, per OAC 317:40-7-6.

(13) Supported employment.

(A) Minimum qualifications. Supported employment providers:

(i) are at least 18 years of age;

(ii) complete the DHS DDS-sanctioned training curriculum;

(iii) were not convicted of, pled guilty to, or pled nolo contendere to misdemeanor assault and battery, or a felony, per Section  1025.2 of Title 56 of the Oklahoma Statutes (O.S. 56 ' 1025.2) unless a waiver is granted, per 56 O.S. ' 1025.5; and

(iv) receive supervision and oversight by a person with a minimum of four years of any combination of college-level education or full-time equivalent experience in serving persons with disabilities.

(B) Description of services.  Supported employment is conducted in a variety of settings, particularly worksites in which persons without disabilities are employed, and includes activities that are outcome based and needed to sustain paid work by members receiving services through HCBS Waivers, including supervision and training. The outcome of supported employment is sustained paid employment at or above minimum wage, but not less than the customary wage and benefit level paid by the employer for the same or similar work performed by individuals without disabilities. The paid employment occurs in an integrated setting in the general workforce in a job that meets personal and career goals.

(i) When supported-employment services are provided at a worksite in which persons without disabilities are employed, payment:

(I) is made for the adaptations, supervision, and training required by members as a result of their disabilities; and

(II) does not include payment for the supervisory activities rendered as a normal part of the business setting.

(ii) Services include:

(I) job coaching per OAC 317:40-7-7;

(II) enhanced job coaching per OAC 317:40-7-12;

(III) employment training specialist services per OAC 317:40-7-8; and

(IV) stabilization per OAC 317:40-7-11.

(iii) Supported-employment services furnished under HCBS Waivers are not available under a program funded by the Rehabilitation Act of 1973 or Individuals with Disabilities Education Act (IDEA).

(iv) Documentation that the service is not otherwise available under a program funded by the Rehabilitation Act of 1973 or IDEA must be maintained in the record of each member receiving the service.

(v) Federal financial participation (FFP) may not be claimed for incentive payment subsidies or unrelated vocational training expenses, such as:

(I) incentive payments made to an employer to encourage or subsidize the employer's participation in a supported employment program;

(II) payments passed through to users of supported-employment programs; or

(III) payments for vocational training not directly related to a member's supported-employment program.

(C) Coverage limitations.  A unit is 15 minutes and payment is made per OAC 317:40-7-1 through 317:40-7-21. All prevocational services and supported-employment services combined cannot exceed $27,000, per Plan of Care year. The DDS case manager assists the member to identify other alternatives to meet identified needs above the limit. The services that may not be provided to the same member, at the same time as supported-employment services are:

(i) HTS;

(ii) Intensive Personal Supports;

(iii) Adult Day Services;

(iv) Daily Living Supports;

(v) Homemaker; or

(vi) therapy services, such as occupational therapy; physical therapy; nutrition, speech, or psychological services, family counseling, or family training, except to allow the therapist to assess the individual's needs at the workplace or to provide staff training.

(14) Intensive personal supports (IPS).

(A) Minimum qualifications.  IPS provider agencies must have a current provider agreement with OHCA and DHS DDS. Providers:

(i) are at least 18 years of age;

(ii) complete the DHS DDS-sanctioned training curriculum;

(iii) were not convicted of, pled guilty to, or pled nolo contendere to misdemeanor assault and battery, or a felony, per Section 1025.2 of Title 56 of the Oklahoma Statutes (O.S. 56 ' 1025.2) unless a waiver is granted, per 56 O.S. ' 1025.2;

(iv) receive supervision and oversight by a person with a minimum of four years of any combination of college-level education or full-time equivalent experience in serving persons with disabilities; and

(v) receive oversight regarding specific methods to be used with the member to meet the member's complex behavioral or health support needs.

(B) Description of services.

(i) IPS:

(I) are support services provided to members who need an enhanced level of direct support in order to successfully reside in a community-based setting; and

(II) build upon the level of support provided by a HTS or daily living supports (DLS) staff by utilizing a second staff person on duty to provide assistance and training in self-care, daily living, and recreational and habilitation activities.

(ii) The member's Individual Plan (IP) must clearly specify the role of HTS and the person providing IPS to ensure there is no duplication of services.

(iii) Review and approval by the DDS plan of care reviewer is required.

(C) Coverage limitations.  IPS are limited to 24 hours per day and must be included in the member's IP, per OAC 317:40-5-151 and 317:40-5-153.

(15) Adult day services.

(A) Minimum qualifications.  Adult day services provider agencies must:

(i) meet the licensing requirements, per 63 O.S. ' 1-873  et seq. and comply with OAC 310:605; and

(ii) be approved by the DHS DDS director and have a valid OHCA contract for adult day services.

(B) Description of services.  Adult day services provide assistance with the retention or improvement of self-help, adaptive and socialization skills, including the opportunity to interact with peers in order to promote a maximum level of independence and function. Services are provided in a non-residential setting away from the home or facility where the member resides.

(C) Coverage limitations.  Adult day services are furnished four or more hours per day on a regularly scheduled basis, for one or more days per week. A unit is 15 minutes for up to a maximum of six hours daily, at which point a unit is one day. All services must be authorized in the member's IP.

 

 

317:30⊂chapter=5∂=51--483.Diagnosis codes [REVOKED]
[Revoked 07-01-13]

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.