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MAC Meeting Agenda

September 17, 2009 at 1 p.m.
OHCA Board Room
4545 N. Linicoln, Suite 124
Oklahoma City, OK 73105

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Tentative Agenda

I. Welcome, Roll Call, and Public Comment Instructions

II. Approval of minutes of the July 16, 2009 Medical Advisory Committee Meeting

III. MAC Member Comments/Discussion

IV. Financial Report: Carrie Evans, Chief Financial Officer

V. Program Operations & Benefits Update: Becky Pasternik-Ikard, Chief Operating Officer

VI. Provider Services Support Update: Paul Keenan, MD, Chief Medical Officer

VII. Extrapolation Rule Update, Cindy Roberts, Deputy Chief Executive Officer

VIII. Retreat Review, Cindy Roberts, Deputy Chief Executive Officer

IX. Action Items:  John Giles, Sr. Policy Specialist

OHCA Initiated

09-04 - Self-Directed Services, Agency Model - This rule standardizes the operation of all self-directed service programs implemented through the SoonerCare program. The rule sets forth minimum requirements that all self- directed service programs must adhere to. Self-direction is a method of service delivery that allows members to determine what services and supports they need to live successfully in a home and community based setting. Budget neutral.

09-33 - Conflicts of Interest - Agency rules are written to comply with the Oklahoma Ethics Commission rules and statutes concerning ethics and conflicts of interests. These rules provide direction for agency employees and supervisors regarding other employment outside of the agency, including other employment with an agency contractor or medical provider. Rules necessitate a conflict review in any instance that an agency employee is employed with an agency contractor or medical provider.  Such reviews may restrict employees from actions involving prior authorization approvals, rule-making and/or rate-setting requests and/or decisions. Budget neutral. 

09-35 DME Ownership - DME rules are revised to establish a policy of ownership for all purchased durable medical equipment, prosthetics, orthotics, and supplies. This rule allows all durable medical equipment purchased by SoonerCare to remain the property of OHCA to be used for the benefit of the requesting member until it is no longer medically necessary. This is the first rule in complying with Oklahoma state law (56 O.S. 1011.11) mandating OHCA to promulgate rules and establish procedures necessary to implement a durable medical equipment retrieval program. Budget neutral.

09-36 - Member Cost Sharing - SoonerCare Assignment and Cost Sharing rules are revised to: (1) clarify that the $1.00 co-payment assessed certain members is per visit rather than per service; and (2) clarify that the $.50 co-payment for Medicare Part B crossover claims is per visit rather than per service. Other revisions update procedures to current practice and correct terminology. BUDGET IMPACT: $182,605 annually. State share approximately $45,651.

09-39 - Behavioral Health Rehabilitation Services – Outpatient Behavioral Health rules are revised to allow family inclusion during Behavioral Health Rehabilitation Services.  This revision will provide consistency between OHCA policy and practices. Budget neutral.

09-41 - Dental – Space Maintainers – Dental rules are revised to allow for the use of unilateral space maintainers for SoonerCare members receiving outpatient oral surgery, rather than bilateral space maintainers, due to fabrication limitations for dental providers in an outpatient surgery setting. Additionally the rule provides that a lingual arch bar may only be used when all permanent incisors are in position.  BUDGET IMPACT: Approximately $85,246 annually. State share approximately $21,311 annually.

09-42 – DME Clarification – DME rules are revised to provide further clarification in regards to the services available to adults and the additional services available to children. These revisions will further align policy with reimbursement practices and help alleviate confusion to the provider community. Revisions include specifying general coverage for adults, providing definition and clarification in regards to adult and children coverage of prosthetics and orthotics, specifying general coverage for children, and general policy cleanup as it relates to these sections. Budget Neutral.

09-49 - Bariatric Surgery Rules - Bariatric surgery rules are revised to re-order the prior authorization process in policy and provide further clarification of the prior authorization process. This revision effectively re-orders policy to present member candidacy guidelines prior to presenting coverage guidelines. This will facilitate the current prior authorization process and encourage providers to request a member candidacy prior authorization before requesting the prior authorization for the surgery. These revisions are not changing the prior authorization process, only reinforcing the current process. Budget Neutral. 

OKDHS Initiated

09-45 - ADvantage Case Management - The Oklahoma Department of Human Services/Aging Services Division has requested an amendment to Case Management rules furnished under the ADvantage Home and Community Based Services waiver. Revisions would increase the current time frame allowed for case managers to complete and submit an individualized care plan and service plan for the member from ten to fourteen days. Additional revisions outline a schedule for the annual service plan reassessment and procedures for submission of materials to the ADvantage Administration. Budget Neutral.

09-48 - DDSD Self-Directed Services - This new rule creates policy to allow SoonerCare members receiving services through the In-Home Supports Waivers the option to self-direct their services. Self-direction provides the opportunity for members to exercise choice and control in accessing, and managing specific waiver services and supports in accordance with their needs and personal preferences. The policy covers operation of the program, including agency oversight, budgeting, member eligibility, member responsibility, and the use of a fiscal agent. BUDGET IMPACT: Expected budget savings of 3% to 4% over traditional In-Home Supports Waiver Services. OKDHS/DDSD pays the state share. 

09-50 - Personal Care Assistants - The Oklahoma Department of Human Services/Aging Services Division has requested an amendment to rules that would revise who could be paid to serve as a Personal Care Assistant (PCA) to SoonerCare members approved for State Plan Personal Care services. Current policy allows the OKDHS Director under certain circumstances to approve payment entirely from OKDHS state funds for Personal Care to a legally responsible family member. OKDHS has requested the discontinuance of this exception as a cost saving measure since OKDHS is responsible for paying the entire cost of the PCAs' services for these individuals. Currently, there are ten individuals who will be affected by this revision to policy; these individuals will remain eligible for Personal Care services and efforts are being made to find other non-related PCAs for these individuals. State Savings: $67,953 annually. OKDHS will continue to provide the state share.

X. New Business

XI. Adjourn

Next Meeting:  November 19th


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