OHCA Policies and Rules

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317:50-1-9. Member annual level of care re-evaluation and annual re-authorization of service plan

[Revised 09-14-18]

(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 for certification along with 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 eleven (11) months, the case manager makes a home visit to evaluate the Medically Fragile Waiver member using the Uniform Comprehensive Assessment Tool (UCAT),  Parts I and III and other information as necessary as part of the annual service plan development process. 

(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 member is evaluated for the continued need for skilled nursing facility or hospital level of care.

(3) Based on evaluation of the UCAT, a determination of continued medical eligibility is made and recertification of medical eligibility is done prior to the 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 sixty (60) days, whichever is less. If the member no longer meets medical eligibility, upon making the level of care determination, the member's medical eligibility end date is updated in the system. The member's case manager is notified that the member has been determined to no longer meet medical eligibility for Medically Fragile Waiver services as of the effective date of the eligibility determination.  The member is notified and if the member requests, the case manager helps the member arrange alternate services in place of Medically Fragile Waiver services.

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.