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317:35-17-16.Member annual level of care re-evaluation and annual re-authorization of service plan

[Revised 09-14-18]
(a) The ADvantage case manager reassesses the member's needs annually using the Uniform Comprehensive Assessment Tool (UCAT) Parts I and III, then evaluates the progress of the member toward person-centered service plan goals and objectives.  The ADvantage case manager develops the annual person-centered service plan with the member and interdisciplinary team and submits the person-centered service plan to the ADvantage Administration (AA) for authorization. The ADvantage case manager initiates the UCAT reassessment and development of the annual person-centered service plan at least forty (40) calendar days, but not more than sixty (60) calendar days, prior to the end date of the existing person-centered service plan. The ADvantage case manager provides AA the reassessment person-centered service plan packet no less than thirty (30) calendar days prior to the end date of the existing plan. The reassessment person-centered service plan packet includes the person-centered service plan, UCAT Parts I and III, Nursing Assessment and Monitoring Tool and supporting documentation.

(b) The Oklahoma Department of Human Services (DHS) nurse reviews the UCAT Parts I and III submitted by the ADvantage case manager for a level of care redetermination. When policy defined criteria for nursing facility level of care cannot be determined or justified from available documentation or through direct contact with the ADvantage case manager, UCAT Parts I and III are completed in the member's home by the DHS nurse. The DHS nurse submits the UCAT evaluation to the area nurse or nurse designee, to make the medical eligibility level of care determination.

(c) When medical eligibility redetermination is not made prior to the current medical eligibility expiration, the existing medical eligibility certification is automatically extended.

(1) For members who are not receiving inpatient; acute care, long term acute care, rehab or skilled nursing services, the existing medical eligibility certification is extended for a maximum of sixty (60) calendar days from the date the previous medical eligibility expiration date.

(2) For members who are receiving inpatient; acute care, long term acute care, rehab or skilled nursing services, the existing medical eligibility certification is extended for thirty (30) calendar days from the date of discharge from the facility or the sixty (60)calendar  days from the date of the previous medical eligibility date, whichever is longer.

(3) When the medical eligibility redetermination is not made by the applicable extended deadline, the member is determined to no longer meet medical eligibility. The area nurse or nurse designee updates the system's medical eligibility end date and simultaneously notifies AA electronically. 

(d) When DHS determines a member no longer meets medical eligibility, to receive waiver services, the:

(1) area nurse or nurse designee updates the medical eligibility end date and notifies the AA electronically;

(2) AA communicates to the member's ADvantage case manager that the member was determined to no longer need medical eligibility for ADvantage as of the effective date of the eligibility determination; and

(3) ADvantage case manager communicates with the member and when requested, assists with access to other 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.