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317:35-15-10.Redetermination of medical eligibility for personal care services
[Revised 09-01-17]

(a) Medical eligibility redetermination.  The Oklahoma Department of Human Services (DHS) area nurse must complete a redetermination of medical eligibility before the end of the long-term care medical certification period.

(b) Recertification.  The DHS nurse re-assesses the personal care services member for medical re-certification based on the member's needs and level of caregiver support required, using the Uniform Comprehensive Assessment Tool (UCAT) at least every 36 months. During this re-certification assessment, the DHS nurse informs the member of the state's other SoonerCare long-term care options. The DHS nurse submits the re-assessment to the DHS area nurse for recertification. Documentation is sent to the DHS area nurse no later than the 10th-calendar day of the month in which the certification expires. When the DHS area nurse determines medical eligibility for personal care services, a recertification review date is entered on the system.

(c) Change in amount of units or tasks.  When the personal care provider agency determines a need for a change in the amount of units or tasks within the personal care service, a new Service Authorization Model (SAM) packet is completed and submitted to DHS within five-calendar business days of identifying the assessed need. The change is approved or denied by the DHS area nurse or designee, prior to implementation.

(d) Voluntary closure of Personal Care services.  When a member decides personal care services are no longer needed to meet his or her needs, a medical decision is not needed. The member and the DHS nurse or DHS county Social Services Specialist completes and signs DHS Form 02AG038E, State Plan Personal Care/ADvantage Program Voluntary Withdrawal Request. The DHS nurse submits closure notification to the provider agency.

(e) Resuming Personal Care services.  When a member approved for Personal Care services is without Personal Care services for less than 90 calendar-days but has current medical and SoonerCare financial eligibility approval, Personal Care services may be resumed using the member's previously approved SAM packet. The personal care provider agency nurse contacts the member to determine when changes in health or service needs occurred. When changes are identified, the provider agency nurse makes a home visit and submits a Personal Care services skilled nursing re-assessment of need within 10-business days of the resumed plan start date, using the State Plan Personal Care Progress Notes, DHS Form 02AG044E. When the member's needs dictate, the Personal Care provider agency may submit a request for a change in authorized Personal Care services units with a SAM packet to DHS. When no changes occur, the agency nurse documents the contact on State Plan Personal Provider Communication Form 02AG032E and forwards it to the DHS nurse within 10-business days of the resumed plan start date.

(f) Financial ineligibility.  When the DHS determines a Personal Care services member does not meet SoonerCare financial eligibility criteria, the DHS office notifies the DHS area nurse to initiate the closure process due to financial ineligibility. Individuals determined financially ineligible for Personal Care services are notified by DHS in writing of the determination and of their right to appeal the decision. The DHS nurse submits closure notification to the provider agency.

(g) Closure due to medical ineligibility.  Individuals determined medically ineligible for Personal Care services are notified by DHS in writing of the determination and of their right to appeal the decision. The DHS nurse submits closure notification to the provider agency.

(h) Termination of State Plan Personal Care Services.

(1) Personal Care services may be discontinued when:

(A) the member poses a threat to self or others as supported by professional documentation;

(B) other members of the household or persons who routinely visit the household who, as supported by professional documentation or other credible documentation, pose a threat to the member or other household visitors;

(C) the member or the other household members use:

(i) angry, insulting, threatening, intimidating, degrading, or sexually inappropriate language; or

(ii) innuendos or behavior towards service provider, whether in the home or through other contact or communications; or

(iii) as supported by professional documentation or other credible documentation.

(D) the member or family member fails to cooperate with Personal Care service delivery or to comply with Oklahoma Health Care Authority (OHCA) or DHS rules as supported by professional documentation;

(E) the member's health or safety is at risk as supported by professional documentation;

(F) additional services, either "formal" such as, paid by Sooner Care or some other funding source or "informal" such as, unpaid are provided in the home eliminating the need for SoonerCare Personal Care services;

(G) the individual's living environment poses a physical threat to self or others as supported by professional documentation where applicable, and measures to correct hazardous conditions or assist the person to move are unsuccessful or are not feasible; or

(H) the member refuses to select and/or accept the services of a provider agency or PCA for 90-consecutive days as supported by professional documentation.

(2) For persons receiving personal care services, the personal care provider agency submits documentation with the recommendation to discontinue services to DHS. The DHS nurse reviews the documentation and submits it to the DHS area nurse for determination. The DHS nurse notifies the personal care provider agency or PCA, and the local DHS county worker of the decision to terminate services. The member is sent an official closure notice informing him or her of appropriate member rights to appeal the decision to discontinue services.

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.