Library: Policy

317:30-5-762. Coverage

Revised 9-1-17

Individuals receiving ADvantage Program services must be determined eligible for the program and must have an approved person-centered service plan. Any ADvantage Program service provided must be listed on the approved person-centered service plan to prevent institutionalization of the member. Waiver services that are expansions of Oklahoma Medicaid State Plan services may only be provided after the member has exhausted services available under the State Plan.

(1) Consumer-Directed Personal Assistance Services and Supports (CD-PASS), services are available to ADvantage Program members in every county.

(2) ADvantage case managers provide information and materials that explain the CD-PASS service option to members. The ADvantage Administration (AA) provides information and material on CD-PASS to case managers for distribution to members.

(3) The member may request CD-PASS services from his or her case manager or call an AA-maintained toll-free number to request CD-PASS services.

(4) The AA uses the following criteria to determine an ADvantage member's service eligibility to participate in CD-PASS, the:

(A) member's health and safety with CD-PASS services can reasonably be assured based on a review of service history records and review of a member's capacity and readiness to assume employer responsibilities under CD-PASS with any one of the following findings as basis to deny a request for CD-PASS due to inability to assure member health and safety, when the member:

(i) does not have the ability to make decisions about his/her care or service planning and the member's authorized representative is unwilling to assume CD-PASS responsibilities; or

(ii) is unwilling to assume responsibility, or to enlist an authorized representative to assume responsibility, in one or more areas of CD-PASS, such as in service planning assuming the role of employer of the personal services assistant (PSA) or advanced personal services assistant (APSA) provider, in monitoring and managing health or in preparation for emergency backup; or

(iii) member has a recent history of self-neglect or self-abuse as evidenced by Adult Protective Services intervention within the past 12 months and does not have an authorized representative with capacity to assist with CD-PASS responsibilities;

(B) member voluntarily makes an informed choice to receive CD-PASS services. As part of the informed choice decision-making process for CD-PASS, the AA staff or case manager provides consultation and assistance as the member completes a self-assessment of preparedness to assume the role of employer of his or her PSA or APSA. The orientation and enrollment process provides the member with a basic understanding of what is expected of them under CD-PASS, the supports available to assist them to successfully perform employer responsibilities and an overview of the potential risks involved.

(5) The AA uses the following criteria to determine that based upon documentation, a person is no longer allowed to participate in CD-PASS:

(A) the member does not have the ability to make decisions about his or her care or service planning and the member's authorized representative is unwilling to assume CD-PASS responsibilities;

(B) the member is unwilling to assume responsibility or to enlist an authorized representative to assume responsibility in one or more areas of CD-PASS, such as in service planning or in assuming the role of employer of the PSA or APSA provider, or in monitoring and managing health or in preparation for emergency backup;

(C) the member has a recent history of self-neglect or self-abuse as evidenced by Adult Protective Services intervention and does not have an authorized representative with capacity to assist with CD-PASS responsibilities;

(D) the member abuses or exploits the employee;

(E) the member falsifies time-sheets or other work records;

(F) the member, even with CM/CDA and Financial Management Services assistance, is unable to operate within his or her Individual Budget Allocation; or

(G) inferior quality of services provided by the member's PSA or APSA provider(s), inability of the PSA or APSA provider(s) to provide the number of service units the member requires jeopardizing the member's health and/or safety.