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317:35-17-3.ADvantage program services

[Revised 09-01-17]

(a) The ADvantage program is a Medicaid Home and Community Based Waiver used to finance non-institutional, long-term care services for elderly and a targeted group of physically disabled adults when there is a reasonable expectation that within a 30-calendar day period, the person's health, due to disease process or disability, would, without appropriate services, deteriorate and require nursing facility care to arrest the deterioration. Individuals may not be enrolled in ADvantage for the sole purpose of enabling them to obtain Medicaid eligibility. Eligibility for ADvantage is contingent on an individual requiring one or more of the services offered in the Waiver at least monthly in order to avoid institutionalization.

(b) The number of individuals who may receive ADvantage services is limited.

(1) To receive ADvantage services, individuals must meet one of the following categories. He or she must:

(A) be 65 years of age and older; or

(B) be 21 to 64 years of age when physically disabled and not developmentally disabled or when 21 to 64 years of age and not physically disabled, the person has a clinically documented, progressive degenerative disease process that responds to treatment and previously required hospital or nursing facility (NF) level of care services for treatment related to the condition; and requires ADvantage services to maintain the treatment regimen to prevent health deterioration; or

(C) when developmentally disabled, and 21 to 64 years of age; and does not have an intellectual disability or a cognitive impairment related to the developmental disability.

(2) In addition, the individual must meet criteria in (A) through (C). He or she must:

(A) require nursing facility level of care. Refer to Oklahoma Administrative Code (OAC) 317:35-17-2;

(B) meet service eligibility criteria. Refer to OAC 317:35-17-3(f); and

(C) meet program eligibility criteria. Refer to OAC 317:35-17-3(g).

(c) ADvantage members are eligible for limited types of living arrangements. The specific living arrangements are set forth below.

(1) ADvantage program members are not eligible to receive services while residing in an institutional setting including, but not limited to, licensed facilities, such as a hospital, a nursing facility, licensed residential care facility, or licensed assisted living facility, unless the facility is an ADvantage Assisted Living Center or in an unlicensed institutional living arrangement, such as a room and board home/facility.

(2) Additional living arrangements in which members may receive ADvantage services are the member's own home, apartment or independent-living apartment, or a family or friend's home or apartment. A home/apartment unit is defined as a self-contained living space having a lockable entrance to the unit and including a bathroom and food storage/preparation amenities in addition to bedroom/living space.

(3) ADvantage program members may receive services in a shelter or similar temporary-housing arrangement that may or may not meet the definition of home/apartment, in emergency situations, for a period not to exceed 60-calendar days during which location and transition to permanent housing is sought.

(4) For ADvantage members who are full-time students, a dormitory room qualifies as an allowable living arrangement in which to receive ADvantage services for the period during which the member is a student.

(5) Members may receive ADvantage respite services in a nursing facility for a continuous period not to exceed 30-calendar days.

(d) Home and Community Based Waiver Services are outside of the scope of Medicaid State Plan services. The Medicaid Waiver allows OHCA to offer certain Home and Community Based services to an annually capped number of persons who are categorically needy, refer to DHS Form Appendix C-1, Schedule VIII. B. 1., and without such services would be institutionalized. The estimated cost of providing an individual's care outside the nursing facility cannot exceed the annual cost of caring for that individual in a nursing facility. When determining the ADvantage service plan cost cap for an individual, the comparable SoonerCare cost to serve that individual in a NF is estimated.

(e) Services provided through the ADvantage Waiver are:

(1) case management;

(2) respite;

(3) adult day health care;

(4) environmental modifications;

(5) specialized medical equipment and supplies;

(6) physical, occupational, or speech therapy or consultation;

(7) advanced supportive/restorative assistance;

(8) nursing;

(9) skilled nursing;

(10) home-delivered meals;

(11) hospice care;

(12) medically necessary prescription drugs within the limits of the Waiver;

(13) personal care, State Plan or ADvantage personal care;

(14) Personal Emergency Response System (PERS);

(15) Consumer-Directed Personal Assistance Services and Supports (CD-PASS);

(16) Institution Transition Services;

(17) assisted living; and

(18) SoonerCare medical services for individuals 21 years of age and over within the scope of the State Plan.

(f) The DHS area nurse or nurse designee makes a determination of service eligibility prior to evaluating the Uniform Comprehensive Assessment Tool (UCAT) assessment for nursing facility level of care. The following criteria are used to make the service eligibility determination:

(1) an open ADvantage Program Waiver slot, as authorized by the Waiver document approved by the Centers for Medicare and Medicaid Services (CMS), is available to ensure federal participation in payment for services to the individual. When the Department of Human Services/Aging Services (DHS/AS) determines all ADvantage Waiver slots are filled, the individual cannot be certified by DHS as eligible for ADvantage services, the individual's name is placed on a waiting list for entry when an open slot becomes available;

(2) the individual is in the ADvantage targeted service group. The target group are individuals, who:

(A) are frail and 65 years of age and older; or

(B) have a physical disability, are between 21 and 64 years of age, and do not have an intellectual disability or a cognitive impairment; or

(C) have developmental disability, are 21 and 64 years of age, and does not have an intellectual disability or cognitive impairment related to the developmental disability;

(3) the individual is not eligible because he or she poses a physical threat to himself or herself or others as supported by professional documentation;

(4) members of the household or persons who routinely visit the household, as supported by professional documentation, do not pose a threat of harm or injury to the individual or other household visitors;

(5) the individual is not eligible when his or her living environment poses a physical threat to himself or herself or others as supported by professional documentation where applicable, and measures to correct hazardous conditions or assist individuals move are unsuccessful or not feasible.

(g) The State, as part of the Waiver program approval authorization, ensures Centers for Medicare and Medicaid Services (CMS) that each member's health, safety, or welfare can be maintained in his or her home. When a member's identified needs cannot be met through provision of ADvantage program or Medicaid State Plan services and other formal or informal services are not in place or immediately available to meet those needs, the individual's health, safety, or welfare in their home cannot be ensured. The ADvantage Administration (AA) determines ADvantage program eligibility through the service plan approval process. An individual is deemed ineligible for the ADvantage program based on the following criteria:

(1) the individual's needs, as identified by UCAT and other professional assessments cannot be met through ADvantage program services, Medicaid State Plan services, and other formal or informal services;

(2) one or more members of the individual's household pose a physical threat to self or others as supported by professional documentation;

(3) the individual or other household members use threatening, intimidating, degrading, or sexually inappropriate language/innuendo or behavior towards service providers, either in the home or through other contact or communications, and significant efforts were attempted to correct such behavior, as supported by professional documentation or other credible documentation.

(4) the individual or the individual's authorized agent is uncooperative or refuses to participate in service development or service delivery and these actions result in unacceptable increases of risk to the individual's health, safety, or welfare in his or her home, as determined by the individual, the interdisciplinary team, or the AA;

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

(6) the individual provides false or materially inaccurate information necessary to determine program eligibility or withholds information necessary to determine program eligibility;

(7) the individual does not require at least one ADvantage service monthly; and

(8) the individual, his or her family member(s), associate(s), or any other person(s) or circumstances as relates to care and coordination in the individual's living environment produces evidence of illegal drug activity or substances used illegally as intoxicants. This includes:

(A) use, possession, or distribution of illegal drugs;

(B) abusive use of other drugs, such as medication prescribed by a doctor; or

(C) use of substances, such as inhalants including, but not limited to:

(i) typewriter correction fluid;

(ii) air conditioning coolant;

(iii) gasoline;

(iv) propane;

(v) felt tip markers;

(vi) spray paint;

(vii) air freshener;

(viii) butane;

(ix) cooking spray;

(x) paint; and

(xi) glue;

(D) observed intoxication, consumption or sensory indicators, such as smell of the use of an drug or intoxicant by the individual, family members, associates, or any other person(s) present at the time care is provided may be construed as evidence indicative of illegal drug activity or intoxication. This includes drug use or intoxicated activity that is menacing to the member or staff providing services;

(E) the observance of drug paraphernalia or any instrument used in the manufacturing, production, distribution, sale, or consumption of drugs or substances including, but not limited to:

(i) smoking pipes used to consume substances other than tobacco;

(ii) roach clips containing marijuana cigarettes;

(iii) needles and other implements used for injecting drugs into the body;

(iv) plastic bags or other containers used to package drugs;

(v) miniature spoons used to prepare drugs; or

(vi) kits used in the production of synthetic controlled substances including

descriptive materials that accompany the item, describing or depicting its use;

(F) instructions, oral or written, concerning the item or device including, but not limited to, the manner in which the object is labeled and displayed for sale;

(G) the typical use of such items in the community; and/or

(H) testimony of an expert witness regarding use of the item

(h) the case manager provides the AA with professional documentation or other credible documentation to support the recommendation for redetermination of program eligibility. The service providers continue providing services according to the person-centered service plan as provider safety permits until the individual is removed from the ADvantage program. As a part of the procedures requesting redetermination of program eligibility, DHS AS provides technical assistance to the provider for transitioning the individual to other services, and

(i) individuals determined ineligible for ADvantage program services are notified in writing by DHS AS of the determination and of the right to appeal the decision.

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.