The OKDHS area nurse, or nurse designee, makes the medical eligibility determination utilizing professional judgment, the Uniform Comprehensive Assessment Tool (UCAT), Part III, and other available medical information.

• (1) When ADvantage care services are requested or the UCAT is received in the county office:
• (A) the LTC nurse is responsible for completing the UCAT.
• (B) the social worker is responsible for contacting the individual within three working days to initiate the financial eligibility application process.
• (2) Categorical relationship must be established for determination of eligibility for ADvantage services.  If categorical relationship to disability has not already been established, the local social worker submits the same information described in OAC 317:35-5-4(2) to the Level of Care Evaluation Unit (LOCEU) to request a determination of eligibility for categorical relationship. LOCEU renders a decision on categorical relationship to the disabled using the same definition used by SSA.  A follow-up is required by the  OKDHS social worker with the Social Security Administration to be sure their disability decision agrees with the decision of LOCEU.
• (3) Community agencies complete the UCAT, Part I and forwards the form to the county office.  If the UCAT, Part I indicates that the applicant does not qualify for Medicaid long-term care services, the applicant is referred to appropriate community resources.
• (4) The LTC nurse completes the UCAT, Part III assessment visit with the client within 10 working days of receipt of the referral for ADvantage services for a client who is Medicaid eligible at the time of the request.  The LTC nurse completes the UCAT, Part III assessment within 20 working days of the date the Medicaid application is completed for new clients.
• (5) During the assessment visit, the LTC nurse informs the client of medical eligibility and provides information about the different long-term care service options.  If there are multiple household members applying for the ADvantage program, the UCAT assessment is done for the applicant household members during the same visit.  The LTC nurse documents whether the client chooses NF program services or ADvantage program services.  In addition, the LTC nurse makes a level of care and service program recommendation.
• (6) The LTC nurse informs the client and family of agencies certified to deliver ADvantage case management and in-home care services in the local area to obtain the client's primary and secondary informed choices.
• (A) If the client and/or family declines to make a provider choice, the LTC nurse documents that decision on the client choice form.
• (B) The AA uses a rotating system to select an agency for the client from a list of all local certified case management and in-home care agencies.
• (7) The LTC nurse documents the names of the chosen agencies and the agreement (by dated signature) of the client to receive services provided by the agencies.
• (8) If the needs of the client require an immediate interdisciplinary team (IDT) meeting with home health agency nurse participation to develop a care plan and service plan, the LTC nurse documents the need.
• (9) The LTC nurse scores the UCAT, Part III.  The LTC nurse forwards the UCAT, Parts I and III, documentation of financial eligibility, and documentation of the client's case management and in-home care agency  choices to the area nurse, or nurse designee, for medical eligibility determination.
• (10) If, based upon the information obtained during the assessment, the LTC nurse determines that the client may be at risk for health and safety, OKDHS Adult Protective Services (APS) staff are notified immediately and the referral is documented on the UCAT.
• (11) Within ten working days of receipt of a complete ADvantage application, the area nurse, or nurse designee, determines medical eligibility using NF level of care criteria and service eligibility criteria [refer to OAC 317:35-17-2 and OAC 317:35-17-3] and enters the medical decision on the system.  The original documents are sent with the MS-52 to the AA.
• (12) Upon notification of financial eligibility from the social worker, medical eligibility (MS-52) and approval for ADvantage entry from the area nurse, or nurse designee, the AA communicates with the client and case management provider to begin care plan and service plan development.  The AA communicates to the client's case management provider the client's name, address, case number and social security number, the units of case management and, if applicable, the number of units of home health agency nurse evaluation authorized for care plan and service plan development, whether the needs of the client require an immediate IDT meeting with home health agency nurse participation and the effective date for client entry into ADvantage.
• (13) If the services must be in place to ensure the health and safety of the client upon discharge to the home from the NF, the AA provides administrative case management to develop and implement the care plan and service plan.  For administrative case management, the AA, or a nurse case manager from an ADvantage case management provider selected by the client and referred by the AA follows ADvantage case management procedures for care plan and service plan development and implementation.  If the AA has provided transition case management services, when the client returns home, the AA begins transitioning case management to the ADvantage case management provider chosen by the client.
• (14) If a client in a hospital requests ADvantage services, the hospital initiates a request for Medicaid ADvantage services by contacting the AA for intake and screening.
• (A) The AA, or a nurse case manager from an ADvantage case management provider selected by the client and referred by the AA completes the UCAT, Part III assessment visit, if possible, with the hospitalized applicant.  If the local OKDHS office receives the request for Medicaid ADvantage services for a client in a hospital it is referred to the AA.  During the assessment visit, the AA, or ADvantage nurse case manager informs the client of financial and medical eligibility criteria and provides information about the different long-term care service options.  The AA, or ADvantage nurse case manager documents the client's choice on the UCAT, Part III.  The AA, or ADvantage nurse case manager will review forms documenting the selection of provider(s), agreement with the service plan and release of information with the client and obtain the client's dated signature on the forms.
• (B) If the UCAT indicates the client is eligible for ADvantage services and financial eligibility has been determined, the AA, or ADvantage nurse case manager, in consultation with the hospital discharge planner provides administrative case management.  The AA, or ADvantage nurse case manager develops a temporary care plan and service plan if services must be in place to ensure the health and safety of the client upon discharge from the hospital.  When the client returns home, the AA, or ADvantage nurse case manager transitions case management to the ADvantage case management provider chosen by the client.
• (C) The completed assessment forms are submitted to the OKDHS area nurse who makes the medical eligibility decision, enters it on the system and notifies the AA of the decision.
• (D) If the applicant is determined not eligible for ADvantage, providers follow special procedures specified by the AA to bill for services provided.  If authorized by the AA, case management providers may bill using an administrative case management procedure code for services delivered and not reimbursable under any other ADvantage case management procedure code.
• (15) If the client has a current certification and requests a change from Personal Care Services to ADvantage services, a new UCAT is required.  The UCAT is updated when a client requests a change from ADvantage services to Personal Care services, or when a client requests a change from the nursing facility to ADvantage services.  If a client is receiving ADvantage services and requests to go to a nursing facility, a new medical level of care decision is not needed.
• (16) When a UCAT assessment has been completed more than 90 days prior to submission to the area nurse or nurse designee for a medical decision, a new assessment is required.