35-15-4. Determination of medical eligibility for State Plan Personal Care

(a) Eligibility. The Oklahoma Human Services (OKDHS) Health Care Management Nurse (HCMN) III determines medical eligibility for SPPC services based on the Uniform Comprehensive Assessment Tool (UCAT) and the determination that the member has unmet care needs that require personal care assistance. SPPC services are initiated to support the regular care provided in the member's home. SPPC services are not intended to take the place of regular care, general maintenance tasks, or meal preparation provided by natural supports, such as spouses or other adults who live in the same household. Additionally, SPPC services are not furnished when they principally benefit the family unit. To be eligible for SPPC services, the applicant:

(1) Has adequate informal supports. This means there is adult supervision that is present or available to contribute to care, or decision-making ability, as documented on the UCAT. To remain in his or her home without risk to his or her health, safety, and well-being, the applicant:

(A) Has the decision-making ability to respond appropriately to situations that jeopardize his or her health and safety, or has available supports that compensate for his or her lack of ability as documented on the UCAT; or

(B) Has his or her decision-making ability, lacks the physical capacity to respond appropriately to situations that jeopardize health and safety, and an OKDHS HCMN I or II informed him or her of potential risks and consequences of remaining in the home.

(2) Requires a care plan for planning and administering services delivered under a professional personnel's supervision;

(3) Has a physical impairment or combination of physical and mental impairments as documented on the UCAT. An applicant who poses a threat to himself or herself or others, as supported by professional or credible documentation, may not be approved for SPPC services. An individual who is actively psychotic or believed to be in danger of potential harm to himself or herself or others may not be approved;

(4) Does not have household members or persons who routinely visit the household who, as supported by professional or credible documentation, pose a threat of harm or injury to the applicant or other household visitors;

(5) Lacks the ability to meet personal care needs without additional supervision or assistance, or to communicate needs to others; and

(6) Requires assistance, not of a technical nature, to prevent or minimize physical health regression and deterioration.

(b) Definitions. The following words and terms, when used in this subsection, shall have the following meaning, unless the context clearly indicates otherwise:

(1) "Activities of Daily Living" (ADL) means activities that reflect the applicant's or member's ability to perform self-care tasks essential for sustaining health and safety, such as:

(A) Bathing;

(B) Eating;

(C) Dressing;

(D) Grooming;

(E) Transferring, including activities such as getting in and out of a tub or moving from bed to chair;

(F) Mobility;

(G) Toileting; and

(H) Bowel or bladder control.

(2) "ADLs score of three (3) or greater" means the applicant or member cannot do at least one (1) ADL at all or needs some help with two (2) or more ADLs.

(3) "Applicant or Member support very low" means the applicant's or member's UCAT Support score is zero (0), this indicates, in the UCAT assessor's clinical judgment, the formal and informal sources are sufficient for the applicant's or member's present need level in most functional areas.

(4) "Applicant or Member support low" means the member's UCAT Support score is five (5), this indicates, in the UCAT assessor's clinical judgment, the support from formal and informal sources are nearly sufficient for the applicant's or member's present need level in most functional areas. The applicant or member, family, or informal supports are meeting most needs typically expected of family or household members to share or do for one another, such as general household maintenance. There is little risk of institutional placement with loss of current supports.

(5) "Applicant or Member support moderate" means the UCAT applicant or member score is fifteen (15), this indicates, in the UCAT assessor's clinical judgment, the formal and informal support is available, but overall, it is inadequate, changing, fragile, or otherwise problematic. The applicant or member requires additional assistance that usually includes personal care assistance with one (1) or more ADLs not available through Medicare, the Veterans Administration, or other federal entitlement programs. Informal caregiver support is considered questionable or unreliable due to one (1) or more criteria in (A) through (D) of this paragraph:

(A) Care or support is required continuously with no relief or backup available;

(B) Informal support lacks continuity due to conflicting responsibilities such as work or child care;

(C) Persons with advanced age or disability provide care; or

(D) Institutional placement can reasonably be expected with any loss of existing support.

(6) "Applicant or Member support high" means the applicant or member score is twenty-five (25) this indicates, in the UCAT assessor's clinical judgment, the formal and informal supports are not sufficient as there is very little or no support available to meet the applicant's or member's high degree of need.

(7) "Community Services Worker" means any non-licensed health professional employed by or under contract with a community services provider who provides, for compensation or as a volunteer, health-related services, training, or supportive assistance to frail elderly, disabled person(s), or person(s) with developmental disabilities.

(8) "Community Services Worker Registry" means an OKDHS established registry established by the OKDHS per Section 1025.3 of Title 56 of the Oklahoma Statutes (O.S.) listing community services workers who have a final investigative finding of abuse, neglect, or exploitation, per 43A O.S. '§10-103, involving a frail elderly person, or person(s) with developmental or other disabilities was made by OKDHS or an administrative law judge.

(9) "Instrumental Activities of Daily Living (IADL)" means those daily activities that reflect the applicant or member's ability to perform household chores and tasks within the community essential for sustaining health and safety, such as:

(A) Shopping;

(B) Cooking;

(C) Cleaning;

(D) Managing money;

(E) Using a phone;

(F) Doing laundry;

(G) Taking medication; and

(H) Accessing transportation.

(10) "IADLs score is at least six (6)" means the applicant or member needs some help with at least three (3) IADLs or cannot do two (2) IADLs at all.

(11) "IADLs score of eight (8) or greater" means the applicant or member needs some help with at least four (4) IADLs or the member cannot do two (2) IADLs at all and needs some help with one (1) or more other IADLs.

(12) "MSQ" means the Mental Status Questionnaire.

(13) "MSQ moderate risk range" means a total weighted-score of seven (7) to eleven (11) that indicates an orientation-memory-concentration impairment or memory impairment.

(14) "Nutrition moderate risk" means a total weighted UCAT Nutrition score is eight (8) or greater that indicates poor appetite or weight loss combined with special diet requirements, medications, or difficulties in eating.

(15) "Social Resource score is eight (8) or more" means the applicant or member lives alone, has no informal support when he or she is sick or needs assistance, or has little or no contact with others.

(d) Medical eligibility determination. OKDHS HCMN III determines medical eligibility for SPPC services utilizing the UCAT.

(1) Categorical relationship is established for SPPC services financial eligibility determination.

(A) When categorical relationship to Aid to the Disabled is not established, but there is an extremely emergent need for personal care, and current medical information is not available, the local office authorizes a medical examination.

(B) When authorization is necessary, the county director issues Form 08MA016E, Authorization for Examination, and Form 08MA02E, Report of Physician's Examination, to a licensed medical or osteopathic health care professional, refer to Oklahoma Administrative Code (OAC) 317:30-5-1.

(C) The licensed health care professional cannot be in a medical facility internship, residency, or fellowship program or in the full-time employment of the Veterans Administration, United States Public Health Service, or other agency.

(D) The OKDHS county worker submits the information to the Level of Care Evaluation Unit (LOCEU) to request a medical eligibility determination for categorical relationship. LOCEU renders a decision on the categorical relationship using the Social Security Administration (SSA) definition. The OKDHS county worker is required to conduct a follow-up with SSA to ensure the SSA disability decision is also the LOCEU decision.

(2) Approved contract agencies or the ADvantage Administration (AA) may complete the electronic application. This alerts the social services specialist (SSS) of application date.

(3) Upon referral receipt, OKDHS SSS starts the financial eligibility determination.

(4) The OKDHS HCMN I or II is responsible for completing the UCAT assessment visit within ten (10) business days of the in-home application for the applicant who is SoonerCare eligible at the time of the request. The OKDHS HCMN I or II completes the assessment visit within twenty (20) business days of the referral for the applicant not determined SoonerCare eligible at the time of the request. When the application indicates the request is from an individual who resides at home and an immediate response is required to ensure the applicant's health and safety, to prevent an emergency situation, or to avoid institutional placement, the UCAT assessment visit has top-scheduling priority.

(A) For initial level of care (LOC) for applicants younger then eighteen (18) years of age, the OKDHS nurse assesses applicants through a face-to-face visit using the UCAT.

(B) For initial LOC for applicants eighteen (18) years of age or older, the OKDHS nurse assesses applicants through electronic format, such as phone or video conference, using the UCAT unless there are limiting factors which necessitate a face-to-face assessment.

(i) The OKDHS nurse determines LOC based upon the assessment outcome unless the applicant is medially ineligible. In this case, a face-to-face visit is scheduled to either validate the initial electronic format assessment or to provide additional documentation to support the applicant meeting medical LOC.

(ii) Applicants are not medically denied access to services solely based on the assessment completed through an electronic format.

(5) During the assessment visit, the OKDHS HCMN I or II completes the UCAT and reviews rights to privacy, fair hearing, provider choice, and the pre-service acknowledgement agreement with the member. The OKDHS HCMN I or II gives the applicant information about medical eligibility criteria and OKDHS long-term care service options. OKDHS HCMN I or II documents if the member wants to be considered for nursing facility level of care services or if the member is applying for a specific service program on the UCAT. When, based on the information obtained during the assessment, the OKDHS HCMN I or II determines if the member may be at risk for health and safety, an immediate referral is made to Adult Protective Services or Child Protective Services, as applicable. The referral is documented on the UCAT.

(A) When SPPC services are not sufficient to meet the applicant's or member's needs, the OKDHS HCMN I or II provides information about other community long-term care service options. The OKDHS HCMN I or II assists in accessing service options applicant or member selects in addition to, or in place of, SPPC services.

(B) When multiple household members are applying for SoonerCare SPPC services, the UCAT assessment is done for all the household members at the same time.

(C) The OKDHS HCMN I or II provides the applicant or member with information about the qualified agencies in his or her local area that provide services and obtains the applicant's or member's primary and secondary agency choice. When the applicant or family declines to choose a primary personal care service agency, the round-robin rotation system is used for agency selection. The OKDHS HCMN I or II documents the selected personal care provider agency's name.

(6) The OKDHS HCMN I or II completes the UCAT in the electronic system, and the OKDHS HCMN III makes the medical eligibility determination. SPPC service eligibility is established on the date medical eligibility is approved and financial eligibility is established. This date serves as the certification date for services to be initiated.

(A) When the time length from the initial assessment to the date of service eligibility determination exceeds ninety (90) calendar days, a new UCAT assessment is required.

(B) The OKDHS HCMN III assigns a medical certification period of not more than thirty-six (36) months for persons eighteen (18) years of age and older or not more than twelve (12) months for persons younger than eighteen (18) years of age. The service plan period is for twelve (12) months.

(7) The SSS is notified via the electronic system of the personal care certification.

(8) Upon establishing SPPC certification, the OKDHS HCMN I or II notifies the applicant's or member's preferred provider agency, or when necessary, the secondary provider agency or the provider agency selected by the round robin rotation system. Within one (1) business day of provider agency acceptance, the OKDHS HCMN I or II submits the information via electronic system to the provider agency for plan development. Refer to OAC 317:35-15-8(a).

(9) Following the provider agency's SPPC plan development, and within three (3) business days of receipt from the provider agency, the OKDHS HCMN I or II reviews the documentation to ensure agreement with the plan. Once agreement is established, the plan is authorized or submitted to the OKDHS HCMN III for review.

(10) Within ten (10) business days of the SPPC plan receipt from the OKDHS HCMN I or II, the OKDHS HCMN III authorizes or denies the plan units. If the plan fails to meet standards for authorization, it is returned to the OKDHS HCMN I or II for further justification.

(11) Within one (1) business day of knowledge of the authorization, the OKDHS HCMN I or II submits the plan authorization to the provider agency via electronic system.

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.