(a) Medical eligibility redetermination.  The OKDHS area nurse, or designee, must complete a redetermination of medical eligibility before the end of the long-term care medical certification period.

(b) Recertification.  The OKDHS 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 UCAT at least every 36 months.  During this re-certification assessment, the OKDHS nurse informs the member of the state's other SoonerCare long-term care options.  • 1  The OKDHS nurse submits the re-assessment to the OKDHS area nurse, or designee, for re-certification.  Documentation is sent to the OKDHS area nurse, or designee, no later than the tenth day of the month in which the certification expires.  When the OKDHS area nurse, or designee determines medical eligibility for Personal Care services, a re-certification review date is entered on the system.

(c) Change in amount of units or tasks within Personal Care service for Personal Care service members.  When the Personal Care services agency determines a need for a change in the amount of units or tasks within the Personal Care service, a new Personal Care Service Authorization Model (SAM) packet is completed and submitted to OKDHS.  The change is approved or denied by the OKDHS area nurse, or designee prior to implementation.

(d) Voluntary closure of Personal Care services.  If a member decides Personal Care services are no longer needed to meet his/her needs, a medical decision is not needed.  The member and the OKDHS nurse or OKDHS county worker completes and signs OKDHS form 02AG038E, AG-17, Voluntary Action of Personal Care Case Closure form.

(e) Resuming Personal Care services.  If a member approved for Personal Care services has been without Personal Care services for less than 90 days but still has a current Personal Care services medical and SoonerCare financial eligibility approval, Personal Care services may be resumed using the member's previously approved Service Authorization Model (SAM) packet.  The Personal Care service agency submits a Personal Care services skilled nursing re-assessment of need within ten working days of the resumed plan start date using the State Plan Personal Care Progress Notes, OKDHS form 02AG044E.  If the member's needs dictate, the Personal Care services agency may submit a request for a change in authorized Personal Care services units with a Service Authorization Model (SAM) packet to OKDHS.  • 2

(f) Financial ineligibility.  Anytime OKDHS determines a Personal Care services member does not meet the SoonerCare financial eligibility criteria, the local OKDHS office notifies the member, Personal Care service provider, and the OKDHS nurse of financial ineligibility.

(g) Closure due to medical ineligibility.  If the local OKDHS office is notified through the system that a member is no longer medically eligible for Personal Care, the OKDHS county worker notifies the member of the decision.  The OKDHS nurse notifies the Personal Care service agency.

(h) Termination of State Plan Personal Care Services.

• (1) Personal Care services may be discontinued if:
  • (A) the member poses a threat to self or others as supported by professional documentation; or
  • (B) other members of the household or persons who routinely visit the household who, as supported by professional documentation, pose a threat of harm or injury to the member or other household visitors; or
  • (C) the member or family member fails to cooperate with Personal Care service delivery or to comply with OHCA or  OKDHS rules as supported by professional documentation; or
  • (D) the member's health or safety is at risk as supported by professional documentation; or
  • (E) additional services, either "formal" (i.e., paid by SoonerCare or some other funding source) or "informal" (i.e., unpaid) are provided in the home eliminating the need for SoonerCare Personal Care services.
• (2) The member refuses to select and/or accept the services of  a Personal Care service agency or PCA for 90 consecutive days as supported by professional documentation.
• (3) For persons receiving Personal Care services, the Personal Care services agency submits documentation with the recommendation to discontinue services to OKDHS.  The OKDHS nurse reviews the documentation and submits it to the OKDHS Area Nurse for determination.  The OKDHS nurse notifies the member and the Personal Care service agency or PCA, and the local OKDHS county worker of the decision to terminate services.  The member is sent an official closure notice informing them of their appropriate member rights to appeal the decision to discontinue services.