AAU Provider Update: June 5, 2012
ADvantage Members Living in an Assisted Living Without ADvantage Authorization
Please see below the policy regarding ADvantage Members living in an Assisted Living center without ADvantage Assisted Living service option authorization.
If an ADvantage Member moves into your facility without the receipt of an ADv6g authorizing this service then the Member becomes ineligible for ADvantage waiver services and the case will be closed and eligibility would be denied due to the Member residing in an institution. Any ADvantage services that are provided to the Member during this period of time could result in an overpayment and could be subject to recoupment from both the Member and the Provider.
If closure of the case does occur and the Member desires to have ADvantage Assisted Living services, ADvantage eligibility processes would start over with a new application date and under new policy and procedures.
(a) The ADvantage program is a Medicaid Home and Community Based Waiver used to finance non-institutional long-term care services for elderly and a targeted group of physically disabled adults when there is a reasonable expectation that within a 30 day period, the person's health, due to disease process or disability, would, without appropriate services, deteriorate and require nursing facility care to arrest the deterioration. ADvantage program members must be SoonerCare eligible and must not reside in an institution, room and board, licensed residential care facility, or licensed assisted living facility, unless the facility is an ADvantage Assisted Living Center. The number of individuals who may receive ADvantage services is limited.
(1) To receive ADvantage services, individuals must meet one of the following categories:
(A) be age 65 years or older, or
(B) be age 21 or older if physically disabled and not developmentally disabled or if the person has a clinically documented, progressive degenerative disease process that responds to treatment and previously has required hospital or nursing facility (NF) level of care services for treatment related to the condition and requires ADvantage services to maintain the treatment regimen to prevent health deterioration, or
(C) if developmentally disabled and between the ages of 21 and 65, not have mental retardation or a cognitive impairment related to the developmental disability.
(2) In addition, the individual must meet the following criteria:
(A) require nursing facility level of care [see OAC 317:35-17-2];
(B) meet service eligibility criteria [see OAC 317:35-17-3(d)]; and
(C) meet program eligibility criteria [see OAC 317:35-17-3(e)].
If you have any questions or concerns regarding the information provided above, please feel free to contact us via email at Provider Questions.