317:35-17-16. Member annual level of care re-evaluation and annual service plan reauthorization
(a) The ADvantage case manager reassesses the member's needs annually using the Uniform Comprehensive Assessment Tool (UCAT), then evaluates the member's progress toward person-centered service plan goals and objectives. The ADvantage case manager develops the annual person-centered service plan with the member and interdisciplinary team and submits the person-centered service plan to the ADvantage Administration (AA) for authorization. The ADvantage case manager initiates the UCAT reassessment and develops the annual person-centered service plan at least forty (40) calendar days, but not more than sixty (60) calendar days, prior to the existing plan's end date. The ADvantage case manager provides AA the person-centered service plan reassessment documents no less than thirty (30) calendar days prior to the existing plan's end date. The reassessment documents include the person-centered service plan, UCAT, Nursing Assessment and Monitoring Tool and supporting documentation.
(b) For medical eligibility reassessment, Oklahoma Human Services (OKDHS) recertification nurse reviews the UCAT the ADvantage case manager submitted. When policy defined criteria for nursing facility LOC cannot be determined or justified from available documentation or through direct contact with the ADvantage case manager, the member is referred to the local OKDHS nurse. The OKDHS nurse then re-assesses the applicant using the UCAT through an electronic format such as a phone and video conference, unless there are limiting factors which necessitate a face-to-face assessment.
(1) The OKDHS nurse determines LOC based on the assessment's outcome unless the applicant is determined to be medically ineligible. In this case, a face-to-face visit is scheduled to either validate the electronic format assessment or provide additional documentation to support the applicant meeting medical LOC.
(2) Applicants are not medically denied access to the waiver solely based on an assessment completed through an electronic format.
(c) When medical eligibility redetermination is not made prior to the current medical eligibility expiration, the existing medical eligibility certification is automatically extended.
(1) For members who are not receiving inpatient acute care, long term acute care, rehab or skilled nursing services, the existing medical eligibility certification is extended for a maximum of sixty (60) calendar days from the date of the previous medical eligibility expiration date.
(2) For members who are receiving inpatient acute care, long term acute care, rehab or skilled nursing services, the existing medical eligibility certification is extended for thirty (30) calendar days from the facility discharge date, or for sixty (60)calendar days from the previous medical eligibility's date, whichever is longer.
(3) When the medical eligibility redetermination is not made by the applicable extended deadline, the member no longer meets medical eligibility. The area nurse or nurse designee updates the system's medical eligibility end date.
(d) When OKDHS determines a member no longer meets medical eligibility to receive waiver services, the:
(1) Area nurse or nurse designee updates the medical eligibility end date;
(2) AA communicates to the member's ADvantage case manager that the member no longer meets medical eligibility for ADvantage as of the eligibility determination effective date; and
(3) ADvantage case manager communicates with the member and when requested, assists with access to other services.