Oklahoma Department of Human Services
Sequoyah Memorial Office Building, 2400 N. Lincoln Blvd. • Oklahoma City, OK 73105
(405) 521-3646 • Fax (405) 521-6684 • Internet: www.okdhs.org
 
317:35-17-3. ADvantage program services
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Revised 7-1-13

 

(a) The ADvantage program is a Medicaid Home and Community Based Waiver used to finance non-institutional long-term care services for elderly and a targeted group of physically disabled adults when there is a reasonable expectation that within a 30 day period, the person's health, due to disease process or disability, would, without appropriate services, deteriorate and require nursing facility care to arrest the deterioration.  Individuals may not be enrolled in ADvantage for the sole purpose of enabling them to obtain Medicaid eligibility.  Eligibility for ADvantage is contingent on an individual requiring one or more of the services offered in the waiver at least monthly in order to avoid institutionalization.

(b) The number of individuals who may receive ADvantage services is limited.

  • (1) To receive ADvantage services, individuals must meet one of the following categories:
    • (A) be age 65 years or older, or
    • (B) be age 21 or older if physically disabled and not developmentally disabled or if age 21 or older and not physically disabled, the person has a clinically documented, progressive degenerative disease process that responds to treatment and previously has required hospital or nursing facility (NF) level of care services for treatment related to the condition and requires ADvantage services to maintain the treatment regimen to prevent health deterioration, or
    • (C) if developmentally disabled and between the ages of 21 and 65, not have intellectual disability or a cognitive impairment related to the developmental disability.
  • (2) In addition, the individual must meet the following criteria:
    • (A) require nursing facility level of care [see OAC 317:35-17-2];
    • (B) meet service eligibility criteria [see OAC 317:35-17-3(f)]; and
    • (C) meet program eligibility criteria [see 317:35-17-3(g)].

(c) ADvantage members are eligible for limited types of living arrangements.  The specific living arrangements are set forth below.

  • (1) ADvantage program members are not eligible to receive services while residing in an institutional setting, including but not limited to licensed facilities such as a hospital, a nursing facility, a licensed residential care facility, or a licensed assisted living facility, (unless the facility is an ADvantage Assisted Living Center), or in an unlicensed institutional living arrangement such as a room and board home/facility. 
  • (2) ADvantage program members may receive services in a contracted ADvantage Assisted Living Center; an ADvantage Assisted Living Center is the only housing-with-nursing-supervised personal care services option in which a person may appropriately receive ADvantage services. 
  • (3) Additional living arrangements in which members may receive ADvantage services are the member's own home, apartment or independent living apartment or a family or friend's home or apartment. A home/apartment unit is defined as a self-contained living space having a lockable entrance to the unit and including a bathroom and food storage/preparation amenities in addition to bedroom/living space.
  • (4) ADvantage program members may receive services in a shelter or similar temporary housing arrangement which may or may not meet the definition of home/apartment, in emergency situations, for a period not to exceed sixty (60) days during which location and transition to permanent housing is being sought.
  • (5) For ADvantage members who are full-time students, a dormitory room qualifies as an allowable living arrangement in which to receive ADvantage services for the period during which the member is a student.
  • (6) Members may receive ADvantage respite services in a nursing facility for a continuous period not to exceed thirty (30) days.

(d) Home and Community Based Waiver Services are outside the scope of Medicaid State Plan services.  The Medicaid waiver allows the OHCA to offer certain Home and Community Based services to an annually capped number of persons who are categorically needy (refer to OKDHS form 08AX001E (Appendix C-1), Schedule VIII. B. 1.) and without such services would be institutionalized.  The estimated cost of providing an individual's care outside the nursing facility cannot exceed the annual cost of caring for that individual in a nursing facility.  When determining the ADvantage service plan cost cap for an individual, the comparable SoonerCare cost to serve that individual in a nursing facility is estimated.  (e) Services provided through the ADvantage waiver are:

  • (1) case management;
  • (2) respite;
  • (3) adult day health care;
  • (4) environmental modifications;
  • (5) specialized medical equipment and supplies;
  • (6) physical therapy/occupational therapy/speech therapy or consultation;
  • (7) advanced supportive/restorative assistance;
  • (8) nursing;
  • (9) skilled nursing;
  • (10) home delivered meals;
  • (11) hospice care;
  • (12) medically necessary prescription drugs within the limits of the waiver;
  • (13) personal care (state plan) or ADvantage personal care;
  • (14) Personal Emergency Response System (PERS);
  • (15) Consumer-Directed Personal Assistance Services and Supports (CD-PASS);
  • (16) Institution Transition Services;
  • (17) assisted living; and
  • (18) SoonerCare medical services for individuals age 21 and over within the scope of the State Plan.

(f) The OKDHS area nurse or nurse designee makes a determination of service eligibility prior to evaluating the UCAT assessment for nursing facility level of care.  The following criteria are used to make the service eligibility determination:

  • (1) an open ADvantage Program waiver slot, as authorized by the waiver document approved by the Centers for Medicare and Medicaid Services (CMS), is available to assure federal participation in payment for services to the individual.  If the OKDHS/ASD determines all ADvantage waiver slots are filled, the individual cannot be certified on the OKDHS computer system as eligible for ADvantage services and the individual's name is placed on a waiting list for entry as an open slot becomes available.
  • (2) the individual is in the ADvantage targeted service group. The target group is an individual who is frail and 65 years of age or older or age 21 or older with a physical disability and who does not have intellectual disability or a cognitive impairment.
  • (3) the individual is not eligible if he/she poses a physical threat to self or others as supported by professional documentation.
  • (4) members of the household or persons who routinely visit the household, as supported by professional documentation, do not pose a threat of harm or injury to the individual or other household visitors.
  • (5) the individual is not eligible if his/her living environment poses a physical threat to self or others as supported by professional documentation where applicable, and measures to correct hazardous conditions or assist the person to move are unsuccessful or not feasible. 

(g) The State, as part of the waiver program approval authorization, assures CMS that each member's health, safety or welfare can be maintained in their home.  If a member's identified needs cannot be met through provision of ADvantage program or Medicaid State Plan services and other formal or informal services are not in place or immediately available to meet those needs, the individual's health, safety or welfare in their home cannot be assured.  The AA determines ADvantage program eligibility through the service plan approval process.  An individual is deemed ineligible for the ADvantage program based on the following criteria:

  • (1) the individual's needs as identified by UCAT and other professional assessments cannot be met through ADvantage program services, Medicaid State Plan services and other formal or informal services.  The State, as part of the waiver program approval authorization, assures CMS that each waiver individual's health, safety, or welfare can be maintained in their home.  If a member's identified needs cannot be met through provision of ADvantage program or Medicaid State Plan
  • services and other formal or informal services are not in place or immediately available to meet those needs, the individual's health, safety or welfare in their home cannot be assured.
  • (2) the individual members of the individual's household, and/or the conditions of the living environment itself, pose a physical threat to self or others as supported by professional documentation and measures to correct conditions are unsuccessful, or are not feasible.
  • (3) the individual or other household members use threatening, intimidating, degrading, or sexually inappropriate language/innuendo or behavior towards service providers, either in the home or through other contact or communications, and significant efforts have been attempted to correct such behavior, as supported by professional documentation.
  • (4) the individual or the individual=s authorized agent is uncooperative or refuses to participate in service development or service delivery and these actions result in unacceptable increases of risk to the individual=s health, safety, or welfare in their home, as determined by the individual, the interdisciplinary team, or the AA.
  • (5) the individual's living environment poses a physical threat to self or others as supported by professional documentation, where applicable and measures to correct hazardous conditions or assist the person to move are unsuccessful or are not feasible.
  • (6) the individual provides false or materially inaccurate information that is necessary to determine program eligibility, or withholds information that is necessary to determine program eligibility.
  • (7) the individual does not require at least one ADvantage service monthly.

(h) The case manager provides the AA with professional documentation to support the recommendation for redetermination of program eligibility.  The service providers continue providing services according to the service plan as provider safety permits until the individual is removed from the ADvantage program.  As a part of the procedures requesting redetermination of program eligibility, the OKDHS/ASD will provide technical assistance to the Provider for transitioning the individual to other services.

(i) Individuals determined ineligible for ADvantage program services are notified in writing by OKDHS of the determination and of their right to appeal the decision.

 

Last Updated:  11/5/2013