(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
(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
(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
(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).