(a) This rule sets forth the criteria
used to determine whether an individual who is seeking SoonerCare payment for
long term care services needs services at the level of Skilled Nursing
Facility, or Intermediate Care Facility for Individuals with Intellectual
Disabilities (ICF/IID). The criteria set forth in this Section must be used
when determining level of care for individuals seeking SoonerCare coverage of
either facility-based institutional long term care services or Home and
Community Based Services (HCBS) Waivers.
(b) The level of care provided by a
long term care facility or through a HCBS Waiver is based on the nature of the
person's needs and the care, services, and treatment required from
appropriately qualified personnel. The level of care review is a determination
of an individual's physical, mental, and social/emotional status to determine
the appropriate level of care required. In addition to level of care
requirements, other applicable eligibility criteria must be met.
(1) Skilled Nursing facility. Payment is made for the Part A coinsurance
and deductible for Medicare covered skilled nursing facility care for dually
eligible, categorically needy individuals.
(2) Nursing Facility. Care provided by a nursing facility to
members who require professional nursing supervision and a maximum amount of
nonprofessional nursing care due to physical conditions or a combination of
physical and mental conditions.
(3) Intermediate Care Facility for
Individuals with Intellectual Disabilities.
Care for persons with intellectual disabilities or related conditions
to provide health and/or habilitative services in a protected residential
setting. To qualify for ICF/IID level of care, persons must have substantial
functional limitations in three or more of the following areas of major life
(A) Self-care. The individual requires assistance, training,
or supervision to eat, dress, groom, bathe, or use the toilet.
(B) Understanding and use of
language. The individual lacks
functional communication skills, requires the use of assistive devices to
communicate, does not demonstrate an understanding of requests, or is unable to
follow two-step instructions.
(C) Learning. The individual has a valid diagnosis of
intellectual disability as defined in the Diagnostic and Statistical Manual of
(D) Mobility. The individual requires the use of assistive
devices to be mobile and cannot physically self-evacuate from a building during
an emergency without assistive device.
(E) Self-direction. The individual is seven (7) years old or
older and significantly at risk in making age appropriate decisions or an adult
who is unable to provide informed consent for medical care, personal safety, or
for legal, financial, habilitative, or residential issues, and/or has been
declared legally incompetent. The individual is a danger to himself or others
(F) Capacity for independent living. The individual who is seven (7) years old or
older and is unable to locate and use a telephone, cross the street safely, or
understand that it is unsafe to accept rides, food, or money from strangers. Or
an adult who lacks basic skills in the areas of shopping, preparing food,
housekeeping, or paying bills.