317:35-9-45. Determination of medical eligibility for care in a private Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)
(a) Pre-approval of medical eligibility.Pre-approval of medical eligibility for private ICF/IID care is based on level of care requirements per OAC 317:30-5-122. Pre-approval is not necessary for individuals with a severe or profound intellectual disability. Pre-approval is made by Oklahoma Health Care Authority (OHCA) Level of Care Evaluation Unit (LOCEU) analysts.
(b) Application for ICF/IID services.Within 30 calendar days after services begin, the facility must submit:
(1) The original of the ICF/IID Level of Care Assessment form (LTC-300) to LOCEU. Required attachments include:
(A) Current (within 90 days of requested approval date) medical information signed by a physician.
(B) A current (within 12 months of requested approval date) psychological evaluation by a licensed Psychologist or State staff supervised by a licensed Psychologist. The evaluation must include intelligence testing that yields a full-scale intelligence quotient, a full-scale functional or adaptive assessment, as well as the age of onset.
(C) A copy of the pertinent section of the Individual Plan or other appropriate documentation relative to the ICF/IID admission and the need for ICF/IID level of care.
(D) A statement that the member is not an imminent threat of harm to self or others (i.e., suicidal or homicidal).
(2) If pre-approval was determined by LOCEU and the above information is received, medical approval will be entered on an electronic medical case list known as MEDATS. Pre-approval is not needed for individuals with a severe or profound intellectual disability.
(c) Categorical relationship.Categorical relationship must be established for determination of eligibility for long-term medical care. If categorical relationship has not already been established, the proper forms and medical information are submitted to LOCEU. (Refer to OAC 317:35-5-4). In such instances LOCEU will render a decision on categorical relationship using the same definition as used by the SSA. A follow-up is required by the OKDHS social worker with the SSA to be sure that their disability decision agrees with the decision of LOCEU.
(d) Medical eligibility for ICF/IID services.
(1) Individuals must require active treatment per 42 CFR 483.440.
(2) Individuals must have a diagnosis of an intellectual disability or a related condition based on level of care requirements per OAC 317:30-5-122 and results of a current comprehensive psychological evaluation by a licensed Psychologist or State staff supervised by a licensed Psychologist.
(A) Per the Diagnostic and Statistical Manual of Mental Disorders, intellectual disability is a condition characterized by a significantly sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior and originating before 18 years of age.
(B) Per 42 CFR 435.1010, persons with related conditions means individuals who have a severe, chronic disability that meets the following conditions:
(i) It is attributable to cerebral palsy or epilepsy.
(ii) It is attributable to any other condition, other than mental illness, found to be closely related to intellectual disability because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with intellectual disability and requires treatment or services similar to those required for these persons.
(iii) It is manifested before the person reaches age 22.
(iv) It is likely to continue indefinitely.
(v) It results in substantial functional limitations in three or more areas of major life activity per OAC 317:30-5-122.
(C) Conditions closely related to intellectual disability include, but are not limited to the following:
(i) autism or autistic disorder, childhood disintegrative disorder, Rett syndrome and pervasive developmental disorder, not otherwise specified (only if "typical autism");
(ii) severe brain injury (acquired brain injury, traumatic brain injury, stroke, anoxia, meningitis);
(iii) fetal alcohol syndrome;
(iv) chromosomal disorders (Down syndrome, fragile x syndrome, Prader-Willi syndrome);and
(v) other genetic disorders (Williams syndrome, spina bifida, phenylketonuria).
(D) The following diagnoses do not qualify as conditions related to intellectual disability. Nevertheless, a person with any of these conditions is not disqualified if there is a simultaneous occurrence of a qualifying condition:
(i) learning disability;
(ii) behavior or conduct disorders;
(iii) substance abuse;
(iv) hearing impairment or vision impairment;
(v) mental illness that includes psychotic disorders, adjustment disorders, reactive attachment disorders, impulse control disorders, and paraphilias;
(vi) borderline intellectual functioning, developmental disability that does not result in an intellectual impairment, developmental delay or "at risk" designations;
(vii) physical problems (such as multiple sclerosis, muscular dystrophy, spinal cord injuries and amputations);
(viii) medical health problems (such as cancer, acquired immune deficiency syndrome and terminal illnesses);
(ix) milder autism spectrum disorders (such as Asperger's disorder and pervasive developmental disorder not otherwise specified if not "atypical autism");
(x) neurological problems not associated with intellectual deficits (such as Tourette's syndrome, fetal alcohol effects and non-verbal learning disability);or
(xi) mild traumatic brain injury (such as minimal brain injury and post-concussion syndrome).