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Part 5      DETERMINATION OF MEDICAL ELIGIBILITY FOR ICF/IID, HCBW/IID, AND INDIVIDUALS AGE 65 OR OLDER IN MENTAL HEALTH HOSPITALS

317:35-9-45.Determination of medical eligibility for care in a private Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)

[Revised 09-01-17]
(a) Pre-approval of medical eligibility.  Pre-approval of medical eligibility for private ICF/IID care is based on level of care requirements per OAC 317:30-5-122. Pre-approval is not necessary for individuals with a severe or profound intellectual disability. Pre-approval is made by Oklahoma Health Care Authority (OHCA) Level of Care Evaluation Unit (LOCEU) analysts.

(b) Application for ICF/IID services.  Within 30 calendar days after services begin, the facility must submit:

(1) The original of the ICF/IID Level of Care Assessment form (LTC-300) to LOCEU. Required attachments include:

(A) Current (within 90 days of requested approval date) medical information signed by a physician.

(B) A current (within 12 months of requested approval date) psychological evaluation by a licensed Psychologist or State staff supervised by a licensed Psychologist. The evaluation must include intelligence testing that yields a full-scale intelligence quotient, a full-scale functional or adaptive assessment, as well as the age of onset.

(C) A copy of the pertinent section of the Individual Plan or other appropriate documentation relative to the ICF/IID admission and the need for ICF/IID level of care.

(D) A statement that the member is not an imminent threat of harm to self or others (i.e., suicidal or homicidal).

(2) If pre-approval was determined by LOCEU and the above information is received, medical approval will be entered on an electronic medical case list known as MEDATS. Pre-approval is not needed for individuals with a severe or profound intellectual disability.

(c) Categorical relationship.  Categorical relationship must be established for determination of eligibility for long-term medical care. If categorical relationship has not already been established, the proper forms and medical information are submitted to LOCEU. (Refer to OAC 317:35-5-4). In such instances LOCEU will render a decision on categorical relationship using the same definition as used by the SSA. A follow-up is required by the OKDHS social worker with the SSA to be sure that their disability decision agrees with the decision of LOCEU.

(d) Medical eligibility for ICF/IID services.

(1) Individuals must require active treatment per 42 CFR 483.440.

(2) Individuals must have a diagnosis of an intellectual disability or a related condition based on level of care requirements per OAC 317:30-5-122 and results of a current comprehensive psychological evaluation by a licensed Psychologist or State staff supervised by a licensed Psychologist.

(A) Per the Diagnostic and Statistical Manual of Mental Disorders, intellectual disability is a condition characterized by a significantly sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior and originating before 18 years of age.

(B) Per 42 CFR 435.1010, persons with related conditions means individuals who have a severe, chronic disability that meets the following conditions:

(i) It is attributable to cerebral palsy or epilepsy.

(ii) It is attributable to any other condition, other than mental illness, found to be closely related to intellectual disability because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with intellectual disability and requires treatment or services similar to those required for these persons.

(iii) It is manifested before the person reaches age 22.

(iv) It is likely to continue indefinitely.

(v) It results in substantial functional limitations in three or more areas of major life activity per OAC 317:30-5-122.

(C) Conditions closely related to intellectual disability include, but are not limited to the following:

(i) autism or autistic disorder, childhood disintegrative disorder, Rett syndrome and pervasive developmental disorder, not otherwise specified (only if "typical autism");

(ii) severe brain injury (acquired brain injury, traumatic brain injury, stroke, anoxia, meningitis);

(iii) fetal alcohol syndrome;

(iv) chromosomal disorders (Down syndrome, fragile x syndrome, Prader-Willi syndrome);and

(v) other genetic disorders (Williams syndrome, spina bifida, phenylketonuria).

(D) The following diagnoses do not qualify as conditions related to intellectual disability. Nevertheless, a person with any of these conditions is not disqualified if there is a simultaneous occurrence of a qualifying condition:

(i) learning disability;

(ii) behavior or conduct disorders;

(iii) substance abuse;

(iv) hearing impairment or vision impairment;

(v) mental illness that includes psychotic disorders, adjustment disorders, reactive attachment disorders, impulse control disorders, and paraphilias;

(vi) borderline intellectual functioning, developmental disability that does not result in an intellectual impairment, developmental delay or "at risk" designations;

(vii) physical problems (such as multiple sclerosis, muscular dystrophy, spinal cord injuries and amputations);

(viii) medical health problems (such as cancer, acquired immune deficiency syndrome and terminal illnesses);

(ix) milder autism spectrum disorders (such as Asperger's disorder and pervasive developmental disorder not otherwise specified if not "atypical autism");

(x) neurological problems not associated with intellectual deficits (such as Tourette's syndrome, fetal alcohol effects and non-verbal learning disability);or

(xi) mild traumatic brain injury (such as minimal brain injury and post-concussion syndrome).

317:35-9-45.1.Determination of medical eligibility for Non-Technical Medical Care [REVOKED]
[Revoked 6-26-00]

317:35-9-46.Determination of continued medical eligibility for care in NF and private ICF/MR [REVOKED]
[Revoked 6-26-00]

317:35-9-47.Determination of continued medical eligibility for NTMC [REVOKED]
[Revoked 6-26-00]

317:35-9-48.Determination of medical eligibility for care in public ICF/MR
[Revised 6-26-00]
(a) DHS, Developmental Disability Services Division (DDSD) evaluation reports provide case material for referral to the LOCEU for determination of the need for ICF/MR level of care/medical eligibility.
(b) The following procedure is used in handling referrals from a public ICF/MR for determination of eligibility for public assistance and/or long-term care in the community or private ICF/MR. The superintendent of the public ICF/MR refers to DHS DDSD those persons who in the judgement of the facility staff can adequately be cared for in the community. The referral includes (in addition to the social and financial information) current medical information on the Report of Physician's Examination form; the Long Term Care Assessment form; psychological information and, if applicable, Form SMR-103-A, Itemized Statement of Charges for Care and Treatment.
(1) The DDSD upon receiving the referral from the facility forwards the information to the Level of Care Evaluation Unit (LOCEU) to determine the medical eligibility for long-term care in the community. LOCEU enters the medical determination on MEDATS.
(2) In instances where referral is from a public ICF/MR for an individual returning to the home and/or Community Based Waiver Services, the DDSD case manager forwards to the worker the medical eligibility determination for HCBW/MR services along with the latest application and redetermination forms used to determine eligibility for long-term care. A new application will not be required. A case number is assigned retaining the application date, certification date and redetermination of eligibility date.
(3) The superintendent of the facility makes a referral to the county where the guardian or responsible relative resides. If there is no guardian or parent, the superintendent of the facility makes the referral to the county where the public ICF/MR is located. The county is responsible for taking the application, determining eligibility, certifying the case and for locating an ICF/MR for the applicant in the appropriate county (this may be within the county or in another county in the State). The date of application on these referrals from the public ICF/MR is the date the superintendent made the referral.
(4) If a facility is located in another county, the complete active case is transferred in the usual manner to the county in which the ICF/MR is located. The transferring county is responsible for notifying the superintendent of the public ICF/MR when an active case is transferred to another county.
(5) When an individual is discharged from a public ICF/MR to return home and/or Community Based Waiver Services, the MRP or MRE case is updated with a discharge date, placed in closed status and retained in the county where the facility is located.

317:35-9-48.1.Determining ICF/IID institutional level of care for TEFRA children
[Revised 09-01-17]

In order to determine ICF/IID level of care for TEFRA children:

(1) The child must be age 18 years or younger and expected to meet the following criteria for at least 30 days.

(A) Applicants under age three must:

(i) have a diagnosis of a developmental disability; and

(ii) have been evaluated by the SoonerStart Early Intervention Program or other appropriate healthcare provider, and found to have severe dysfunctional deficiencies with findings of at least two standard deviations in at least two total domain areas.

(B) Applicants age three years and older must:

(i) have a diagnosis of intellectual disability or a developmental disability; and

(ii) have received a psychological evaluation by a licensed psychologist or school psychologist certified by the Oklahoma Department of Education (ODE) within the last 12 months. The evaluation must include intelligence testing that yields a full-scale intelligence quotient, and a full-scale functional or adaptive assessment that yields a composite functional age. Eligibility for TEFRA ICF/IID level of institutional care requires an IQ of 70 or less, or a full-scale functional assessment indicating a functional age composite that does not exceed fifty percent of the child's chronological age. In no case shall eligibility be granted for a functional age greater than eight years.

(2) Psychological evaluations are required for children who are approved for TEFRA under ICF/IID level of care. Children under evaluation, including both intelligence testing and adaptive/functional assessment, by a licensed psychologist or school psychologist certified by the ODE, at age three, age six, and, if medically necessary, thereafter to ascertain continued eligibility for TEFRA under the ICF/IID level of institutional care. The psychological evaluation must be completed and submitted to the LOCEU no later than 90 days following the child's third and sixth birthday, and, if medically necessary, thereafter.

317:35-9-49.Determination of medical eligibility for Home and Community Based Waiver Services for the Intellectually Disabled
[Revised 6-25-12]
Determinations of medical eligibility for Home and Community Based Waiver Services for the Intellectually Disabled (HCBW/ID) is made through referral to the DHS DDSD case manager.
(1) Referral. If the county receives an application, Form K-13 is forwarded to the DDSD case manager, who is responsible for securing a HCBW/ID medical determination and a disability decision, if needed.
(2) Initial request. If the initial request is through DDSD, Form K-13 is forwarded to the county for completing the application process.
(3) Plan of care packet. The DDSD case manager submits the necessary information to LOCEU for medical determination and a disability decision if needed.
(4) County notification. LOCEU notifies the county and DDSD case manager of determination by updating the MEDATS file.
(5) Procedures for an individual returning home. If referral is from a public ICF/MR for an individual returning to the home, the DDSD case manager forwards to the worker the medical eligibility determination for HCBW/ID along with the latest application form and redetermination of eligibility form used to determine eligibility for institutional care. A new application will not be required. A case number will be assigned retaining the application date, certification date and redetermination of eligibility date.
(6) Determination of continued eligibility for HCBW/ID. The case manager is responsible for assuring that the individual's needs are re-evaluated and that recertification is established annually. Determination of continued medical eligibility is not necessary unless there is a significant change in the client=s condition. The DDSD cases manager will notify LOCEU if this is the case.
317:35-9-50.Determination of medical eligibility for persons age 65 or older in mental health hospitals
[Issued 7-14-95]
Medical eligibility is determined based on residence in a mental health hospital due to the need for care and treatment provided under the direction of a physician in an institution for mental diseases. Visits are made to the mental health hospital by OHCA staff. Patients' charts are reviewed to determine if continued institutional care is appropriate and the medical records are maintained in accordance with federal regulations. A worksheet is completed on each case showing the findings of the reviews. The worksheets are maintained in the OHCA.

317:35-9-51.Change in level of long-term medical care [REVOKED]
[Revoked 6-26-00]

317:35-9-52.Determination of medical eligibility for the ADvantage waiver [REVOKED]
[Revoked 6-26-00]

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.