OHCA Policies and Rules

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Part 1      SERVICES

317:35-9-1.Overview of long-term medical care services; relationship to QMB, SLMB, and other Medicaid services eligibility, and spenddown calculation
[Revised 06-25-12]
(a) Long Term Medical Care Services. Long-term medical care for the categorically needy includes care in a nursing facility (refer to OAC 317:35-19), public and private intermediate care facility for the mentally retarded (refer to this subchapter), persons age 65 years or older in mental health hospitals (refer to this subchapter), Home and Community Based Waiver Services for the Intellectually Disabled (refer to this subchapter), and Home and Community Based Waiver Services for frail elderly and a targeted group of adults with physical disabilities age 21 and over who have not been determined to have a developmental disability, an intellectual disability or a related condition (refer to OAC 317:35-17). Personal Care provides services in the own home for categorically needy individuals (refer to OAC 317:35-15). Any time an individual is certified as eligible for Medicaid coverage of long-term care, the individual is also eligible for other Medicaid services. Another application or additional spenddown computation is not required. Spenddown is applied to the first long-term care claim filed. Any time an aged, blind or disabled individual is determined eligible for long-term care, a separate determination must be made to see if eligibility conditions as a Qualified Medicare Beneficiary (QMB) or Specified Low-Income Medicare Beneficiary (SLMB) are met. Another application for QMB or SLMB benefits is not required. Any spenddown computed for long-term care is not applicable to QMB or SLMB coverage.
(b) Medicaid recovery. The State of Oklahoma operates a Medicaid Recovery program to recover for services identified in OAC 317:35-9-15. Recovery can be accomplished in two ways: liens against real property or claims made against estates.
317:35-9-2.Services in a Nursing Facility (NF) [REVOKED]
[Revoked 6-26-00]

317:35-9-3.ADvantage program services [REVOKED]
[Revoked 6-26-00]

317:35-9-4.Services in Intermediate Care Facility for Individuals with Intellectual Disabilities (public and private)

[Revised 09-01-17]
(a) Services in a private Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) may be provided to members requiring health or habilitative services above the level of room and board. Services are provided to members who meet level of care and eligibility requirements per OAC 317:30-5-122 and 317:35-9-45.

(b) Services in a public ICF/IID may be provided to members who require health or habilitative services above the level of room and board. Services are provided to members who meet level of care requirements per OAC 317:30-5-122.

317:35-9-5.Home and Community - Based Services (HCBS) Waivers for persons with an intellectual disability or certain persons with related conditions

[Revised 06-25-12]
(a) Home and Community Based Services (HCBS) Waivers for persons with intellectual disabilities or certain persons with related conditions are operated by the Oklahoma Department of Human Services (OKDHS) Developmental Disabilities Services Division (DDSD) per OAC 317:40-1-1. Oklahoma's Medicaid agency, the Oklahoma Health Care Authority (OHCA), provides oversight of Waiver operation. HCBS Waivers allow the OHCA to offer certain home and community based services to categorically needy members who, without such services, would be eligible for care in an Intermediate Care Facility for persons with Mental Retardation (ICF/MR).
(b) Members receiving HCBS Waiver services per OAC 317:40-1-1 are subject to HCBS Waiver service conditions (1)-(11) of this subsection. The rules in this subsection shall not be construed as a limitation of the rights of class members set forth in the Second Amended Permanent Injunction in Homeward Bound vs. The Hissom Memorial Center.
(1) HCBS Waiver services are subject to annual appropriations by the Oklahoma Legislature.
(2) DDSD must limit the utilization of the HCBS Waiver services based on:
(A) the federally-approved member capacity for the individual HCBS Waivers; and
(B) the cost effectiveness of the individual HCBS Waivers as determined according to federal requirements; and
(3) DDSD must limit enrollment when utilization of services under the HCBS Waiver programs is projected to exceed the spending authority.
(4) Members receiving Waiver services must have full access to State plan services for which they are eligible including Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services when children participate in a Waiver.
(5) A member's room and board expenses may not be paid through a Waiver. Room and board expenses must be met from member resources or through other sources.
(6) A member must require at least one Waiver service per month or monthly case management monitoring in order to function in the community.
(7) Waiver services required by a member must be documented in advance of service delivery in a written plan of care.
(8) Members exercise freedom of choice by choosing Waiver services instead of institutional services.
(9) Members have the right to freely select from among any willing and qualified provider of Waiver services.
(10) The average costs of providing Waiver and non-Waiver SoonerCare services must be no more costly than the average costs of furnishing institutional (and other SoonerCare state plan) services to persons who require the same level of care.
(11) Members approved for services provided in a specific Waiver must be afforded access to all necessary services offered in the specific Waiver if the member requires the service.

317:35-9-5.1.Home and Community Based Waiver Services for individuals with mental retardation and related conditions [REVOKED]
[Revoked 6-25-11]
317:35-9-6.Non-Technical Medical Care in own home [REVOKED]
[Revoked 6-26-00]

317:35-9-7.Services for persons age 65 or older in mental health hospitals
[Issued 7-14-95]
Services for persons age 65 years or older in mental health hospitals are mental health services provided in an inpatient hospital setting to eligible categorically needy individuals whose condition cannot adequately be treated on an outpatient basis. These individuals are not eligible for the Qualified Medicare Beneficiary program (QMB) or the Specified Low-Income Medicare Beneficiary program (SLMB).

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.