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Provider Update: November 26, 2019

To:      MSU Case Management and Home Care Providers

Subject:    Eligible Provider Policy Change Related to Exceptions

Effective 10/01/2019 there has been a revision to the policy regarding Eligible Provider Exception (EPE). The following section of Oklahoma Administrative Code allows for Aging Services to approve exceptions to the policy which prohibits a spouse or legal guardian to serve as an ADvantage Member’s paid caregiver. Specifically, the change is to the highlighted criteria for which eligible provider exception can be requested.

OAC 317:30-5-761(7)
(7)    DHS AS may authorize a member's legally-responsible spouse or legal guardian to be SoonerCare (Medicaid) reimbursed, per 1915(c) ADvantage Program as a personal care, service provider. Authorization for a spouse or legal guardian as a provider requires the criteria in (A) through (D) and monitoring provisions to be met.
(A)    Authorization for a spouse or legal guardian to be the care provider for a member may occur only when the member is offered a choice of providers and documentation demonstrates:
(i)    no provider included on the Certified Agency Report (CAR) has available staffing; This is as evidenced by supportive documentation, which affirms no provider within the members service area can staff and all area providers attempt to employ staff to serve; or
       (ii)    the member's needs are so complex that unless the spouse or legal guardian provides the care, the member's risk level would increase; and
(iii)    it is mentally or physically detrimental for someone other than the spouse or legal guardian to provide care. This is evidenced by the documentation from a qualified clinician or medical provider such as a physician or licensed psychologist.

(B)    The service must:

(i)    meet the definition of a service/support as outlined in the federally-approved waiver document;
(ii)    be necessary to avoid institutionalization;
(iii)    be a service/support specified in the person-centered service plan;
(iv)    be provided by a person who meets the provider qualifications and training standards specified in the waiver for that service;
(v)    be paid at a rate that does not exceed that which would otherwise be paid to a provider of a similar service and does not exceed what is allowed by OHCA for the payment of personal care or personal assistance services; and
(vi)    not be an activity the spouse or legal guardian would ordinarily perform or is responsible to perform.

(C)    The spouse or legal guardian service provider complies with:

(i)    providing no more than forty (40) hours of services in a seven-day (7-day) period;
(ii)    planned work schedules that must be available in advance for the member's case manager, and variations to the schedule must be noted and supplied to the case manager two (2) weeks in advance unless the change is due to an emergency;
(iii)    maintaining and submitting time sheets and other required documentation for hours paid; and
(iv)    the person-centered service plan as the member's care provider.

(D)    In addition to case management, monitoring, and reporting activities required for all waiver services, the State is obligated to additional monitoring requirements when members elect to use a spouse or legal guardian as a paid service provider. The AA monitors, through quarterly documentation submitted by the case manager, the continued appropriateness of the policy exception that allows the spouse or legal guardian to serve as the member's paid caregiver.

The Eligible Provider Exception Request (v2) form has been updated to mirror this change to exception criteria. Only requests submitted on the current Harmony EPE Request form will be considered.

For appropriate submission of the EPE Request form:

  • The Eligible Provider Exception Request (v2) form, located in the Documents tab of the Member chapter, must be filled out completely and then printed.

  • The Case Manager obtains all required wet signatures (Member, spouse or legal guardian for whom the exception is being requested, Case Manager, Case Manager Supervisor, and the Home Care RN).
    The signed EPE Request form is then uploaded to a Plan Note in the corresponding service plan year (Member chapter, Plans tab) for which the request is being made.

  • The Note Type must be set to “Eligible Provider Exception (auto submits to MSU)” and the Note Sub Type must be set to “EPE Initial Request.” Make certain to also attach any requested/required supporting documentation.

  • Set the Plan Note Status to Pending, then Save and Close. 

Please send any questions regarding the information above through the Harmony PQ chapter.

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