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
 
317:35-17-5. ADvantage program medical eligibility determination
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Revised 6-25-12

     The OKDHS area nurse, or nurse designee, makes the medical eligibility determination utilizing professional judgment, the Uniform Comprehensive Assessment Tool (UCAT) I, 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 OKDHS nurse is responsible for completing the UCAT III.
    • (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 OKDHS nurse completes the UCAT, Part III assessment visit with the member 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 OKDHS nurse completes the UCAT, Part III assessment within 20 working days of the date the Medicaid application is completed for new applicants.
  • (5) During the assessment visit, the OKDHS nurse informs the applicant 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 OKDHS nurse documents whether the member chooses NF program services or ADvantage program services. In addition, the OKDHS nurse makes a level of care and service program recommendation.
  • (6) The OKDHS nurse informs the member 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 member and/or family declines to make a provider choice, the OKDHS nurse documents that decision on the member choice form.
    • (B) The AA uses a rotating system to select an agency for the member from a list of all local certified case management and in-home care agencies.
  • (7) The OKDHS nurse documents the names of the chosen agencies and the agreement (by dated signature) of the member to receive services provided by the agencies.
  • (8) If the needs of the member require an immediate interdisciplinary team (IDT) meeting with home health agency nurse participation to develop a care plan and service plan, the OKDHS nurse documents the need for priority processing.
  • (9) The OKDHS nurse scores the UCAT, Part III.  The OKDHS nurse forwards the UCAT, Parts I and III, documentation of financial eligibility, and documentation of the member'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 OKDHS nurse determines that the member 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.
  • (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 case management provider to begin care plan and service plan development.  The AA communicates to the client's case management provider the member'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. If the member requires an immediate home visit to develop a service plan within 24 hours, the AA contacts the case management provider directly to confirm availability and then sends the new case packet information to the case management provider via facsimile.
  • (13) If the services must be in place to ensure the health and safety of the member upon discharge to the home from the NF or Hospital, a nurse case manager from an ADvantage case management provider selected by the client and referred by the AA follows ADvantage Institution Transition case management procedures for care plan and service plan development and implementation.
  • (14) A new medical level of care determination is required when a member requests any of the following changes in service program:
    • (A) from State Plan Personal Care to ADvantage services.
    • (B) from ADvantage to State Plan Personal Care services.
    • (C) from Nursing Facility to ADvantage services.
    • (D) from ADvantage to Nursing Facility services.
  • (15) A new medical level of care determination is not required when a member requests re-activation of ADvantage services after a short-term stay (90 days or less) in a Nursing Facility when the member has had previous ADvantage services and the ADvantage certification period has not expired.
  • (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.

 

Last Updated:  7/11/2012