317:30-5-133.1. Routine services
(a) Long-term care facility care includes routine items and services that must be provided directly or through appropriate arrangement by the facility when required by SoonerCare residents. Charges for routine services may not be made to resident's personal funds or to resident family members, guardians, or other parties who have responsibility for the resident. If reimbursement is available from Medicare or another public or private insurance or benefit program, those programs are billed by the facility. In the absence of other available reimbursement, the facility must provide routine services from the funds received from the regular SoonerCare vendor payment and the SoonerCare resident's applied income, or spend down amount.
(b) The Oklahoma Health Care Authority (OHCA) will review the listing periodically for additions or deletions, as indicated. Routine services are member specific and provided in accordance with standard medical care. Routine services include, but are not limited to:
(1) Regular room.
(2) Dietary services:
(A) Regular diets;
(B) Special diets;
(C) Salt and sugar substitutes;
(D) Supplemental feedings;
(E) Special dietary preparations;
(F) Equipment required for preparing and dispensing tube and oral feedings; and
(G) Special feeding devices (furnished or arranged for).
(3) Medically related social services to attain or maintain the highest practicable physical, mental and psycho-social well-being of each resident, nursing care, and activities programs (costs for a private duty nurse or sitter are not allowed).
(4) Personal services - personal laundry services for residents (does not include dry cleaning).
(5) Personal hygiene items (personal care items required to be provided does not include electrical appliances such as shavers and hair dryers, or individual personal batteries), to include:
(A) Shampoo, comb, and brush;
(B) Bath soap;
(C) Disinfecting soaps or specialized cleansing agents when indicated to treat or prevent special skin problems or to fight infection;
(D) Razor and/or shaving cream;
(E) Nail hygiene services; and
(F) Sanitary napkins, douche supplies, perineal irrigation equipment, solutions, and disposable douches.
(6) Routine oral hygiene items, including:
(C) Dental floss;
(D) Lemon glycerin swabs or equivalent products; and
(E) Denture cleaners, denture adhesives, and containers for dental prosthetic appliances such as dentures and partial dentures.
(7) Necessary items furnished routinely as needed to all members, e.g., water pitcher, cup and tray, towels, wash cloths, hospital gowns, emesis basin, bedpan, and urinal.
(8) The facility will furnish as needed items such as alcohol, applicators, cotton balls, tongue depressors and, first aid supplies, including small bandages, ointments and preparations for minor cuts and abrasions, and enema supplies, disposable enemas, gauze, 4 x 4's ABD pads, surgical and micropore tape, telfa gauze, ace bandages, etc.
(9) Over the counter drugs (non-legend) not covered by the prescription drug program (PRN or routine). In general, long-term care facilities are not required to provide any particular brand of non-legend drugs, only those items necessary to ensure appropriate care.
(A) If the physician orders a brand specific non-legend drug with no generic equivalent, the facility must provide the drug at no cost to the member. If the physician orders a brand specific non-legend drug that has a generic equivalent, the facility may choose a generic equivalent, upon approval of the ordering physician;
(B) If the physician does not order a specific type or brand of non-legend drug, the facility may choose the type or brand;
(C) If the member, family, or other responsible party (excluding the long-term care facility) prefers a specific type or brand of non-legend drug rather than the ones furnished by the facility, the member, family or responsible party may be charged the difference between the cost of the brand the resident requests and the cost of the brand generally provided by the facility. (Facilities are not required to provide an unlimited variety of brands of these items and services. It is the required assessment of resident needs, not resident preferences, that will dictate the variety of products facilities need to provide);
(D) Before purchasing or charging for the preferred items, the facility must secure written authorization from the member, family member, or responsible party indicating his or her desired preference, as well as the date and signature of the person requesting the preferred item. The signature may not be that of an employee of the facility. The authorization is valid until rescinded by the maker of the instrument.
(10) The facility will furnish or obtain any necessary equipment to meet the needs of the member upon physician order. Examples include: trapeze bars and overhead frames, foot and arm boards, bed rails, cradles, wheelchairs and/or geriatric chairs, foot stools, adjustable crutches, canes, walkers, bedside commode chairs, hot water bottles or heating pads, ice bags, sand bags, traction equipment, IV stands, etc.
(11) Physician prescribed lotions, ointments, powders, medications and special dressings for the prevention and treatment of decubitus ulcers, skin tears and related conditions, when medications are not covered under the Vendor Drug Program or other third-party payer.
(12) Supplies required for dispensing medications, including needles, syringes including insulin syringes, tubing for IVs, paper cups, medicine containers, etc.
(13) Equipment and supplies required for simple tests and examinations, including scales, sphygmomanometers, stethoscopes, clinitest, acetest, dextrostix, pulse oximeters, blood glucose meters and test strips, etc.
(14) Underpads and diapers, waterproof sheeting and pants, etc., as required for incontinence or other care.
(A) If the assessment and care planning process determine that it is medically necessary for the resident to use diapers as part of a plan to achieve proper management of incontinence, and if the resident has a current physician order for adult diapers, then the facility must provide the diapers without charge;
(B) If the resident or the family requests the use of disposable diapers and they are not prescribed or consistent with the facility's methods for incontinent care, the resident/family would be responsible for the expense.
(15) Members in long-term care facilities requiring oxygen will be serviced by oxygen kept on hand by the long-term care facility as part of the per diem rate.
(16) Other physician ordered equipment to adequately care for the member and in accordance with standard patient care.
(17) Dentures and Services related services. Payment for the cost of dentures and related services is included in the daily rate for routine services. The projected schedule for routine denture services must be documented on the admission plan of care and on the annual plan of care. The medical records must also contain documentation of steps taken to obtain the services. When the provision of denture services is medically appropriate, the long-term care facility must make timely arrangements for the provision of these services by licensed dentists. In the event denture services are not medically appropriate, the treatment plan must reflect the reason the services are not considered appropriate, e.g., the member is unable to ingest solid nutrition or is comatose, etc. When the need for dentures is identified, one (1) set of complete dentures or partial dentures and one (1) dental examination is considered medically appropriate every three (3) years. One (1) rebase and/or one (1) reline is considered appropriate every three (3) years. It is the responsibility of the long-term care facility to ensure that the member has adequate assistance in the proper care, maintenance, identification and replacement of these items. The long-term care facility cannot set up payment limits which result in barriers to obtaining denture services. However, the long-term care facility may restrict the providers of denture services to providers who have entered into payment arrangements with the facility. The facility may also choose to purchase a private insurance dental coverage product for each SoonerCare member. At a minimum, the policy must cover all denture services included in routine services. The member cannot be expected to pay any co-payments and/or deductibles. If a difference of opinion occurs between the long-term care facility, member, and/or family regarding the provision of dentures services, the OHCA will be the final authority. All members and/or families must be informed of their right to appeal at the time of admission and yearly thereafter. The member cannot be denied admission to a facility because of the need for denture services.
(18) Vision services. Routine eye examinations for the purpose of medical screening or prescribing or changing glasses and the cost of glasses are included in the daily rate for routine services. This does not include follow-up or treatment of known eye disease such as diabetic retinopathy, glaucoma, conjunctivitis, corneal ulcers, iritis, etc. Treatment of known eye disease is a benefit of the member's medical plan. The projected schedule for routine vision care must be documented on the admission plan of care and on the annual plan of care. The medical record must contain documentation of the steps that have been taken to access the service. When vision services are not appropriate, documentation of why vision services are not medically appropriate must be included in the treatment plan. For example, the member is comatose, unresponsive, blind, etc. Long-term care facility providers may contract with individual eye care providers, providers groups or a vision plan to provide routine vision services to their members. The member cannot be expected to pay any co-payments and/or deductibles.
(A) The following minimum level of services must be included:
(i) Individuals twenty-one (21) to forty (40) years of age are eligible for one (1) routine eye examination and one (1) pair of glasses every thirty-six (36) months[three (3) years].
(ii) Individuals forty-one (41) to sixty-four (64) years of age are eligible for one (1) routine eye examination and one (1) pair of glasses every twenty-four (24) months [two (2) years].
(iii) Individuals sixty-five (65) years of age or older are eligible for one (1) routine eye examination and one (1) pair of glasses every twelve (12) months (yearly).
(B) It is the responsibility of the long-term care facility to ensure that the member has adequate assistance in the proper care, maintenance, identification and replacement of these items. When vision services have been identified as a needed service, long-term care facility staff will make timely arrangements for provision of these services by licensed ophthalmologists or optometrists. If a difference of opinion occurs between the long-term care facility, member, and/or family regarding the provision of vision services, the OHCA will be the final authority. All members and/or families must be informed of their right to appeal at admission and yearly thereafter. The member cannot be denied admission to the facility because of the need for vision services.
(19) An attendant to accompany SoonerCare eligible members during SoonerRide non-emergency transportation (NET). Please refer to Oklahoma Administrative Code (OAC) 317:30-5-326 through OAC 317:30-5-327.9 for SoonerRide rules regarding members residing in a long-term care facility; and
(20) Influenza and pneumococcal vaccinations.