(a) Annually, the case manager reassesses the member's needs and the service plan, especially with respect to progress of the member toward service plan goals and objectives.  Based on the reassessment, the case manager develops a new service plan with the member and service providers, as appropriate, and submits the new service plan to the AA for certification.  Along with the service plan submitted for annual recertification, the case manager forwards to AA the supporting documentation and the assessment of the existing service plan.  The case manager initiates the fourth quarter monitoring to allow sufficient time for certification of a new service plan prior to the expiration date on the existing service plan.

(b) At a maximum of every 11 months, the ADvantage case manager makes a home visit to evaluate the ADvantage member using the UCAT, Parts I and III and other information as necessary as part of the annual service plan development process.  The OKDHS nurse evaluation substitutes for the case manager's fourth quarter assessment in the client's third year.

• (1) The case manager's assessment of a member done within a 60-day period prior to the existing service plan end date is the basis for medical eligibility redetermination.
• (2) As part of the service plan recertification process, the AA evaluates whether the member continues to meet policy defined criteria for Nursing Facility level of care.
• (3) Except for enrollment years in which the OKDHS nurse is scheduled to do an independent assessment for medical eligibility, the AA notifies OKDHS/ASD electronically of member medical assessment by providing the member's identifying information and the member's UCAT Part III including level of care criteria domain scores to justify member medical eligibility recertification for an additional 12 month period.
• (4) OKDHS/ASD determines whether a member requires further assessment for annual medical eligibility determination.  For a member requiring further assessment, and at least every third year, the OKDHS nurse schedules a home visit with the member to do a UCAT reassessment which will be used for redetermination of medical eligibility.
• (5) The OKDHS nurse submits the UCAT evaluation to the area nurse, or nurse designee, for a determination of continued medical eligibility.  The area nurse, or designee, makes the medical eligibility decision and recertifies medical eligibility prior to expiration date of current medical eligibility certification.  If medical eligibility recertification is not made prior to current medical eligibility expiration, the existing medical eligibility certification is automatically extended until recertification is determined or for 60 days, whichever is less. If the member no longer meets medical eligibility, upon making the level of care determination, the area nurse, or nurse designee, updates the system's "medical eligibility end date" and notifies the AA electronically.  The AA communicates to the member's case manager that the member has been determined to no longer meet medical eligibility for ADvantage as of the effective date of the eligibility determination.  The case manager communicates with the member and if requested, helps the member to arrange alternate services in place of ADvantage.