OKDHS - OAC 317:35-17-2. Level of care medical eligibility determination

317:35-17-2. Level of care medical eligibility determination

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Revised 6-25-12

The OKDHS area nurse, or nurse designee, determines medical eligibility for ADvantage program services based on the Uniform Comprehensive Assessment Tool (UCAT) III assessment and the determination that the member has unmet care needs that require ADvantage or NF services to assure member health and safety. ADvantage services are initiated to support the informal care that is being provided in the member's home, or, that based on the UCAT, can be expected to be provided in the members's home upon discharge of the member from a NF or hospital. These services are not intended to take the place of regular care and general maintenance tasks or meal preparation typically shared or done for one another by spouses or other adults and who live in the same household. Additionally, services are not furnished if they principally benefit the family unit. When there is an informal (not paid) system of care available in the home, ADvantage service provision will supplement the system within the limitations of ADvantage Program policy to enable the family and/or significant others to continue caregiving over extended periods. When the ADvantage personal care attendant and member live within the same household, personal care will only be approved by agreement of the interdisciplinary service planning team and OKDHS AA approval that the personal care tasks are consistent with plan goals and have beneficial outcomes for the member.

(1) Definitions. The following words and terms when used in this subchapter, shall have the following meaning, unless the context clearly indicates otherwise:
- (A) "ADL" means the activities of daily living. Activities of daily living are activities that reflect the member's ability to perform self-care tasks essential for sustaining health and safety such as:
  - (i) bathing,
  - (ii) eating,
  - (iii) dressing,
  - (iv) grooming,
  - (v) transferring (includes getting in and out of a tub, bed to chair, etc.),
  - (vi) mobility,
  - (vii) toileting, and
  - (viii) bowel/bladder control.
- (B) "ADLs score in high risk range" means the member's total weighted UCAT ADL score is 10 or more which indicates the member needs some help with 5 ADLs or that the member cannot do 3 ADLs at all plus the member needs some help with 1 other ADL.
- (C) "ADLs score at the high end of the moderate risk range" means member's total weighted UCAT ADL score is 8 or 9 which indicates the member needs help with 4 ADLs or the member cannot do 3 ADLs at all.
- (D) "Client Support high risk" means member's UCAT Client Support score is 25 which indicates in the UCAT assessor's clinical judgment, excluding from consideration existing Ryan White CARE Act, Indian Health Service, Medicaid NF, ADvantage and/or State Plan Personal Care services, very little or no support is available from informal and formal sources and the overall total support is entirely inadequate to meet a high degree of medically complex needs. Functional capacity is so limited as to require full time assistance and the stability of the care system is likely to fail. The member requires additional care that is not available through Medicare, Veterans Administration, or other Federal entitlement programs to prevent an imminent risk of life threatening health deterioration or institutional placement.
- (E) "Client Support low risk" means member's UCAT Client Support score is 5 which indicates in the UCAT assessor's clinical judgment, excluding from consideration existing Ryan White CARE Act, Indian Health Service, Medicaid NF, ADvantage and/or State Plan Personal Care services, support from informal and formal sources is nearly sufficient/stable with minimal or few needs for formal services (i.e. some housekeeping only). The member/family/ informal supports are meeting most needs typically expected for family/household members to share or do for one another, i.e. general household maintenance. There is little risk of institutional placement even with a loss of current supports.
- (F) "Client Support moderate risk" means member's UCAT Client Support score is 15 which indicates in the UCAT assessor's clinical judgment, excluding from consideration existing Ryan White CARE Act, Indian Health Service, Medicaid NF, ADvantage and/or State Plan Personal Care services, support from informal and formal sources is available, but overall, it is inadequate, changing, fragile or otherwise problematic and the member requires additional care that usually includes personal care assistance with one or more activity of daily living tasks and is not available through Medicare, Veterans Administration, or other federal entitlement programs. Support provided by informal caregivers is of questionable reliability due to one or more of the following:

(i) Care/support is required continuously with no relief or backup available, or
(ii) Informal support lacks continuity due to conflicting responsibilities such as job and/or child care, or
(iii) Care/support is provided by persons with advanced age and/or disability, and
(iv) Institutional placement can reasonably be expected with any loss of existing support.

(G) "Cognitive Impairment" means that the individual, as determined by the clinical judgment of the OKDHS Nurse or the AA, does not have the capability to think, reason, remember or learn skills required for self-care, communicating needs, directing care givers and/or using appropriate judgment for maintenance of their own health or safety. The clinical judgment of cognitive impairment is based on MSQ performance in combination with a more general evaluation of cognitive function from interaction with the individual during the UCAT assessment.
(H) "Developmental Disability" means a severe, chronic disability of an individual that:
- (i) is attributable to a mental or physical impairment or combination of mental and physical impairments;
- (ii) is manifested before the individual attains age 22;
- (iii) is likely to continue indefinitely;
- (iv) results in substantial functional limitations in three or more of the following areas of major life activity:
  - (I) self-care;
  - (II) receptive and expressive language;
  - (III) learning;
  - (IV) mobility;
  - (V) self-direction;
  - (VI) capacity for independent living; and
  - (VII) economic self-sufficiency; and
- (v) reflects the individual?s need for a combination and sequence of special, interdisciplinary, or generic services, supports, or other assistance that is of lifelong or extended duration and is individually planned and coordinated.
(I) "Environment high risk" means member's UCAT Environment score is 25 which indicates in the UCAT assessor's clinical judgment, the physical environment is strongly negative or hazardous.
(J) "Environment low risk" means member's UCAT Environment score is 5 which indicates in the UCAT assessor's clinical judgment that, although aspects of the physical environment may need minor repair/improvement, the physical environment poses little risk to member's health and/or safety.
(K) "Environment moderate risk" means member's UCAT Environment score is 15 which indicates in the UCAT assessor's clinical judgment, many aspects of the physical environment are substandard or hazardous.
(L) "Health Assessment high risk" means member's UCAT health assessment score is 25 which indicates in the UCAT assessor's clinical judgment, the member has one or more chronic health conditions, whose symptoms are rapidly deteriorating, uncontrolled, or not well controlled and requiring a high frequency or intensity of medical care/oversight to bring under control and whose functional capacity is so limited as to require full time assistance or care performed daily, by, or under the supervision of professional personnel and has multiple unmet needs for services available only through the ADvantage program or a Nursing Facility (NF) and requires NF placement immediately if these needs cannot be met by other means.
(M) "Health Assessment low risk" means member's health assessment score is 5 which indicates, in the UCAT assessor's clinical judgment, the member has one or more chronic, stable, health conditions, whose symptoms are controlled or nearly controlled, which benefit from available, or usually available, medical treatment or corrective measures, and may have an unmet need for a service available only through the ADvantage program or a Nursing Facility (NF) but is not likely to enter a NF if these needs are not met.
(N) "Health Assessment moderate risk" means member's UCAT Health Assessment score is 15 which indicates in the UCAT assessor's clinical judgment, the member has one or more chronic changing health conditions, whose symptoms are fragile or worsening and require medical care/oversight, to bring under control or to maintain in a stable, controlled state and has multiple unmet needs for services available only through the ADvantage program or a Nursing Facility (NF) and is likely to enter a NF if these needs are not met.
(O) "IADL" means the instrumental activities of daily living that reflect household chores and tasks within the community essential for sustaining health and safety such as:
- (i) shopping,
- (ii) cooking,
- (iii) cleaning,
- (iv) managing money,
- (v) using a telephone,
- (vi) doing laundry,
- (vii) taking medication, and
- (viii) accessing transportation.
(P) "IADLs score in high risk range" means member's total weighted UCAT IADL score is 12 or more which indicates the member needs some help with 6 IADLs or cannot do 4 IADLs at all.
(Q)"Intellectual Disability" means that the individual has, as determined by a standardized testing by trained professionals, substantial limitations in functional ability due to significantly sub-average intellectual functioning related to an event occurring before the age of 18.
(R) "MSQ" means the mental status questionnaire.
(S) "MSQ score in high risk range" means the member's total weighted UCAT MSQ score is 12 or more which indicates a severe orientation-memory-concentration impairment, or a severe memory impairment.
(T) "MSQ score at the high end of the moderate risk range" means the member's total weighted UCAT MSQ score is (10) or (11) which indicates an orientation-memory-concentration impairment, or a significant memory impairment.
(U) "Nutrition high risk" means a total weighted UCAT Nutrition score is 12 or more which indicates the member has significant eating difficulties combined with poor appetite, weight loss, and/or special diet requirements.
(V) "Progressive degenerative disease process that responds to treatment" means a process such as, but not limited to, Multiple Sclerosis (MS), Parkinson's Disease, Human Immunodeficiency Virus (HIV), or Acquired Immunodeficiency Syndrome (AIDS), that, untreated, systematically impairs normal body function which leads to acute illness and/or disability that results in rapid and/or advanced effects beyond those of regular chronic disease degeneration but that reacts positively to a medically prescribed treatment intervention (usually medication) which arrests or significantly delays the destructive action of the process.
(W) "Reauthorization" means the official approval by the AA of an ADvantage member's Service Plan after the approval/authorization of the member's initial, or first year, Service Plan. At a minimum, reauthorization of an ADvantage member's Service Plan is required every 12 months.
(X) "Recertification" means the formal certification of medical and/or financial eligibility for an ADvantage member by OKDHS within ELDERS and IMS upon completion of the annual review.
(Y) "Redetermination of eligibility" means a subsequent determination of eligibility for an ADvantage member after the initial eligibility decision. Redetermination of financial and medical eligibility for ADvantage members is required at a minimum of once every 12 months. A redetermination of Program Eligibility, although not required, may occur when a significant change in the service plan is authorized or a significant change in the living arrangement occurs.
(Z) "Social Resources high risk" means a total weighted UCAT Social Resources score is 15 or more, which indicates the member lives alone, combined with none or very few social contacts and no supports in times of need.

(2) Minimum UCAT criteria. The minimum UCAT criteria for NF level of care criteria are:
- (A) Care need: The UCAT documents need for assistance to sustain health and safety as demonstrated by:
  - (i) either the ADLs or MSQ score is in the high risk range; or
  - (ii) any combination of two or more of the following:
    - (I) ADLs score is at the high end of moderate risk range; or,
    - (II) MSQ score is at the high end of moderate risk range; or,
    - (III) IADLs score is in the high risk range; or,
    - (IV) Nutrition score is in the high risk range; or,
    - (V) Health Assessment is in the moderate risk range, and, in addition;

(B) Loss of independence: The UCAT documents absence of support or adequate environment to meet the needs to sustain health and safety as demonstrated by:
- (i) Member Support is moderate risk; or,
- (ii) Environment is high risk; or,
- (iii) Environment is moderate risk and Social Resources is in the high risk range; or, regardless of whether criteria under (A) of Care need and (B) Loss of independence;
(C) Expanded criteria: The UCAT documents that:
- (i) the member has a clinically documented progressive degenerative disease process that will produce health deterioration to an extent that the individual will meet OAC 317:35-17-2(2)(A) criteria if untreated; and
- (ii) the member previously has required Hospital or NF level of care services for treatment related to the condition; and
- (iii) a medically prescribed treatment regimen exists that will significantly arrest or delay the disease process; and
- (iv) only by means of ADvantage Program eligibility will the individual have access to the required treatment regimen to arrest or delay the disease process.

(3) NF Level of Care Services. To be eligible for NF level of care services, meeting the minimum UCAT criteria demonstrates the individual must:
- (A) require a treatment plan involving the planning and administration of services that require the skills of licensed or otherwise certified technical or professional personnel, and are provided directly or under the supervision of such personnel;
- (B) have a physical impairment or combination of physical, mental and/or functional impairments;
- (C) require professional nursing supervision (medication, hygiene and/or dietary assistance);
- (D) lack the ability to adequately and appropriately care for self or communicate needs to others;
- (E) require medical care and treatment in order to minimize physical health regression or deterioration;
- (F) require care that is not available through family and friends, Medicare, Veterans Administration, or other federal entitlement program with the exception of Indian Health Services.

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