Library: Policy
317:35-18-9. Continuation of enrollment
Revised 9-12-14
(a) At least annually, OHCA must reevaluate whether a participant continues to meet the level of care required for PACE eligibility.
(b) At least annually, OKDHS will reevaluate the participant's financial eligibility for SoonerCare.
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(1) Waiver of Annual level of Care Reassessment. If the individual meets the state's medical eligibility criteria and the individual has an irreversible or progressive diagnosis or a terminal illness that could reasonably be expected to result in death in the next six months, and OHCA determines that there is no reasonable expectation of improvement or significant change in the condition because of severity of a chronic condition or the degree of impairment of functional capacity, OHCA will permanently waive the annual recertification requirement and the participant will be deemed to be continually eligible for PACE. The assessment form must have sufficient documentation to substantiate the participant's prognosis and functional capacity.
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(2) Deemed Continued Eligibility. If it is determined that a PACE participant no longer meets the medical criteria for nursing facility level of care, the participant will be deemed to continue to be eligible for PACE until the next annual reassessment, if, in the absence of PACE services, it is reasonable to expect that the participant would meet the nursing facility level of care criteria within the next six months.
(c) Participant enrollment continues when OHCA in consultation with the PACE organization, makes a determination of continued eligibility based on a review of the participant's medical record and plan of care. The participant's medical record and plan of care must support deemed continued eligibility.
