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Eligibility Redetermination Process for ADvantage Members

Program Information

​The ADvantage Program is a home and community-based alternative to receiving care in a nursing facility.  The program provides services to Medicaid eligible persons who meet nursing facility level of care eligibility requirements.  The program objective is to offer every individual who requests assistance and is medically and financially eligible, the opportunity to choose between institutional nursing facility care and home and community based services delivered through a personalized plan of care.

Continuing to meet both medical and financial eligibility is a requirement for ongoing participation in the ADvantage Program.  This re-evaluation of eligibility is known as the redetermination process, and is completed in two distinct parts.  Financial eligibility is evaluated on an annual basis by the Oklahoma Human Services (OHS) Social Service Specialis.  Medical eligibility (also known as the medical level of care or nursing facility level of care) is also evaluated annually.  Medical eligibility is determined by the Medicaid Services Unit's team of Recertification Nurses, using the annual UCAT assessment completed by the Member's ADvantage Case Manager.

Service Specialist's responsibility:

  • The Social Service Specialist (SSS) is responsible for completing an annual review of resources through a request for financial documents from the member.
  • This process usually, although not always, starts around the 10th month of the Member's Service Plan Year (also known as the Medical Certification period).
  • If the financial documents requested are not received back on time (usually within 20 days of request), the financial review is closed, making the Member ineligible for ADvantage and ending all services immediately.
  • Services may be reactivated when all documentation has been submitted and the Member is determined to meet the financial eligibility guidelines for ADvantage.

Case Manager's responsibility:

  • Ask the member if they have received anything in the mail from their (SSS).
    • "Have you gotten any papers to fill out for your DHS Case Worker?  You should be receiving some papers very soon asking about your finances."
  • Remind the Member this is an important part of their annual reassessment and must be completed to remain on the Advantage program.
  • Follow up as needed to ensure compliance with the financial review process.
  • If ADvantage services are ended due to non-compliance, support the Member to submit the necessary documentation as quickly as possible.  Services may be reactivated once the financial review is completed and the Member is determined to meet the financial eligibility guidelines for ADvantage.

During the initial assessment for the ADvantage Program, an OHS Health Care Management Nurse completes an assessment for medical eligibility.  The Uniform Comprehensive Evaluation Tool, or UCAT, is the document used to determine medical level of care.  Every year thereafter, the ADvantage Case Manager completes the reassessment UCAT as part of the service plan development process and for assuring continued program eligibility.

Case Manager's responsibility:

  • Monitor each assigned Member's Service Plan dates so the reassessment process is started 40 to 60 days prior to the service plan end date.
  • Complete the annual UCAT assessment, being sure to fully document the Member's current situation, needs and supports.
  • Review the UCAT to make sure that documentation is complete and all scores are justified.
  • Coordinate the IDT, develop the new person-centered service plan, and submit the reassessment service plan packet to the Medicaid Services Unit (MSU) at least 30 days prior to the service plan end date.

Service Plan Authorization Unit's Responsibility:

  • Review and enter the authorized service plan.
  • Inform the Case Manager of any issues affecting authorization of any requested services.

Recertification Nurse's Responsibility:

  • Review the Case Manager's UCAT and score the UCAT Part III for nursing facility level of care.
  • If medical eligibility is approved, enter annual certification dates (consistent with service plan year dates) into the state system.
  • If medical eligibility cannot be approved based upon the Case Manager's UCAT documentation, request an assessment by the OHS County Nurse to evaluate for nursing facility level of care.

Phone numbers:
Main Office: (918) 933-4900
ADvantage CareLine (800) 435-4711

Mailing Address:
PO Box 35900
Tulsa, OK 74153-0900

Target Population:

Per the ADvantage waiver and State policy, an individual between the ages of 21 and 65 having a developmental disability may not participate in the ADvantage program unless they do not have an intellectual disability or cognitive impairment related to the developmental disability.  In other words, individuals having a developmental disability without a cognitive impairment related to that disability may be eligible.

  • For individuals identified in the UCAT as having a developmental disability, it is extremely important to expand upon their history and abilities, as the lack of this information will result in a home visit to determine appropriateness for waiver services.
  • Some indicators that a person having a developmental disability might be appropriate for the ADvantage waiver may include the ability to live alone (currently or in the past), a history of holding down a full-time job and managing personal finances, etc.

Sometimes the Case Manager's documentation in the UCAT Part III does not support or validate the UCAT scores assigned.

  • For example:
    • In the Health Assessment section of the UCAT, it asks if the Member is "…on a special diet that the doctor told you to follow?"  A score of '0' (None) is assigned.  The Health Assessment section of the UCAT indicates the Member has diabetes, high blood pressure, irritable bowel syndrome, and GERD.
    • here are often specific diets related to these (and many other) health conditions.  Probing questions should be asked to discover if the Member has been instructed to follow a particular diet, even if he or she has chosen not to follow it.  Scoring should be based on the number of diets the Member was encouraged to follow by the health care practitioner.  (UCAT Assessor Manual)
    • The Health Assessment section of the UCAT states the Member is incontinent.  In the Functional Assessment section of the UCAT, specifically in the Activities of Daily Living (ADLs) section incontinence is marked yes to indicate the Member uses incontinence briefs.  Bladder/bowel control shows a score of '3' indicating the Member has accidents often, however there is no documentation entered to support this score.
      • In the UCAT Assessor Manual, accidents are defined as incontinence "…severe enough to soak through undergarments, clothing or bedding onto the skin with or without the use of an incontinence appliance or training program." 
      • For scoring purposes, incontinence that does not soak through undergarments, clothing, bedding or incontinence appliance does not indicate an accident.  Without supporting documentation regarding the extent of the incontinence and its impact on the skin, including frequency and type of accidents, this score would be revised to a score of '0.'
    • Also in the Functional Assessment section, a Member is scored as '0' with documentation stating she can manage medications without assistance.  In the Health Assessment section of the UCAT, the Member is noted to have poor eyesight that affects her ability to fill insulin syringes accurately.  A score of '0' indicates the Member has the ability to set up, remember, and take all medications in correct doses and via appropriate methods.  No one is documented to be prefilling insulin syringes.
      • If the Member needs assistance to manage medications, even if no one is providing that assistance, scoring should reflect the level of need.  In this instance, the Member should be scored as '2' as she is able to manage most medications without assistance, although not all.
      • The service planning implications related to the unmet need in managing medications appropriately should also be addressed in the Member's person-centered service plan documents.
    • The Consumer support – clinical judgment section of the UCAT (located in the Caregiver Assessment section) reflects a score of Moderate need, with supporting documentation stating there are two adults living in the home with the Member.  This documentation does not support a score of Moderate need.
      • There are many other factors that may impact the ability of the two adults to provide the necessary care for the Member.  Issues such as both people working outside the home, working long shifts, or having children for whom they also provide care may directly affect caregiving abilities.
      • Documentation must reflect not only identify the presence of informal supports, but also the ability and willingness of the supports to assist the Member.  
      • There are often specific diets related to these (and many other) health conditions.  Probing questions should be asked to discover if the Member has been instructed to follow a particular diet, even if he or she has chosen not to follow it.  Scoring should be based on the number of diets the Member was encouraged to follow by the health care practitioner.  (UCAT Assessor Manual page, pages 43-47)
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