Library: Policy

317:35-16-2. Determination of medical eligibility for State Plan Personal Care (SPPC) services for Expansion Adults, TEFRA, and certain MAGI populations

Issued 3-28-23

(a) Eligibility. The OHCA Clinical Review team (OHCA nurse) determines medical eligibility for SPPC services based on the Uniform Comprehensive Assessment Tool (UCAT) Part III 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 Part III. To remain in his or her home without risk to his or her health, safety, and well-being, the applicant:

(A) Must have 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 Part III; or

(B) His or her decision-making ability, lacks the physical capacity to respond appropriately to situations that jeopardize health and safety, and an OHCA nurse has informed his/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 Part III. 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;

(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 Part III Support score is zero (0), this indicates, in the UCAT Part III 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 Part III Support score is five (5), this indicates, in the UCAT Part III 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 Part III applicant or member score is fifteen (15), this indicates, in the UCAT Part III 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;

(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 Part III 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 aa registry established by the OKDHS per Section (') 1025.1 of Title 56 of the Oklahoma Statutes (O.S.) to list community services workers who have a final investigative finding of abuse, neglect, or exploitation, per 43A O.S. ' 10-103, involving a frail elderly, disabled person(s), or person(s) with developmental disabilities was made by OKDHS or an administrative law judge; and amended in 2002, to include the listing of SoonerCare (Medicaid) personal care assistants (PCAs) providing personal care services.

(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;

(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 Part III 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.

(c) Medical eligibility minimum criteria for SPPC. The medical eligibility minimum criteria for SPPC services are the minimum UCAT score criteria that an applicant or member meets for medical eligibility and are:

(1) ADLs score is five (5) or greater; or has an IADLs score of eight (8) or greater; or Nutrition score is (8) or greater; or the MSQ score is seven (7) or greater; or the ADLs score is three (3) and IADLs score is at least six (6); and

(2) Applicant or Member Support score is fifteen (15) or more; or Applicant or Member Support score is five (5) and the Social Resources score is eight (8) or greater.

(d) Medical eligibility determination. Medical eligibility for personal care is determined by the OHCA. The medical decision for personal care is made by the OHCA supervisor, overseeing SPPC services, utilizing the UCAT Part III. The member will be notified prior to UCAT III assessment that the result could indicate a need for disability review.

(1) Referrals will be made to the OKDHS if the applicant requires a disability review based on information obtained in referral and/or UCAT Part III.

(2) Upon receipt of the referral the OHCA nurse is responsible for completing the UCAT Part III assessment visit within ten (10) business days of the personal care application for the applicant who is SoonerCare eligible at the time of the request. The OHCA nurse 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 Part III assessment visit has top-scheduling priority.

(3) During the assessment visit, the OHCA nurse completes the UCAT III and reviews rights to privacy, fair hearing, provider choice, and the pre-service acknowledgement agreement with the member. The OHCA nurse informs the applicant of medical eligibility criteria and provides information about OHCA long-term care service options. The OHCA nurse 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 Part III. When, based on the information obtained during the assessment, the OHCA nurse 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 Part III.

(A) When the applicant's needs cannot be met by personal care services alone, the OHCA nurse provides information about other community long-term care service options. The OHCA nurse assists in accessing service options the 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 Part III assessment is done for all the household members at the same time.

(C) The OHCA nurse 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 OHCA nurse documents the selected personal care provider agency's name.

(4) The OHCA nurse completes the UCAT Part III and sends it to an alternate OHCA nurse for medical eligibility determination. SPPC services 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 Part III assessment is required.

(B) The OHCA nurse 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 and is provided by the OHCA nurse.

(5) Upon establishing SPPC certification, the OHCA nurse 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 OHCA nurse submits the information via electronic system to the provider agency for plan development. Refer to OAC 317:35-15-8(a).

(6) Following the provider agency's SPPC plan development, and within three (3) business days of receipt from the provider agency, the OHCA nurse reviews the documentation to ensure agreement with the plan. Once agreement is established, the plan is submitted to OHCA Personal Care Supervisor for review and then the plan is authorized.

(7) Within one (1) business day of knowledge of the authorization, the OHCA nurse submits the plan authorization to the provider agency via electronic system.