Okla. Admin. Code § 317:35-19-2

Current through Vol. 42, No. 4, November 1, 2024

Section 317:35-19-2 - Nursing Facility (NF) program medical eligibility determination

The Oklahoma Human Services (OKDHS) area nurse or nurse designee, determines medical eligibility for NF services based on the OKDHS nurse's Uniform Comprehensive Assessment Tool (UCAT) assessment of the client's needed level of care, the outcome of the Level II Preadmission Screening and Resident Review (PASRR), when completed, and his or her professional judgment. The Oklahoma Health Care Authority (OHCA) Level of Care Evaluation Unit (LOCEU) makes some determinations when the PASRR is involved. Refer to Oklahoma Administrative Code (OAC) 317:35-19-7.1(3) for NF level of care medical eligibility requirements.

(1) When NF care services are requested prior to admission, the same rules related to medical eligibility determination identified in OAC 317:35-17-5 for ADvantage services are followed.

(2) The OKDHS nurse reviews the PASRR Level I in the OHCA system; completes the UCAT; and enters the date OHCA received the PASRR Level I (LTC-300R) from the NF and admission date to the NF; medical eligibility effective date and notes any Level II PASRR results if available in the UCAT Part III. This information is submitted to the OKDHS area nurse for medical eligibility determination.

(3) PASRR requirements are identified in OAC 317:35-19-8 and 317:35-19-9.

(4) When it is not possible to complete the UCAT assessment prior to admission, the NF is responsible for notifying OKDHS of the admission. Notification is mailed or faxed on OKDHS Form 08MA083E, Notification Regarding Patient In A Nursing Facility, Intermediate Care Facility for the Intellectually Disabled or Hospice, and Management Recipient Funds to the local OKDHS county office. Upon receipt, the OKDHS county office processes Forms 08MA083E and 08MA084E and completes and forwards the Form 08MA038E, Notice Regarding Financial Eligibility to the NF. Identified sections of the UCAT reflecting the domains for meeting medical criteria are completed for applicants residing in the NF at the time of assessment. The area nurse or nurse designee, confirms the date of medical eligibility and records it in the system. The facility is responsible for performing the PASRR Level I screen and consulting with OHCA staff to determine when a need exists for a Level II screen. The OKDHS nurse completes the assessment within fifteen-business (15-business) days of PASRR clearance when the individual's needs are included in an active OKDHS coded case. When the individual's needs are not included in an active case, the assessment is completed within twenty-business (20-business) days of PASRR clearance.

(5) The area nurse or nurse designee, evaluates the PASRR Level I screen and the UCAT in consultation with the OKDHS nurse when the completed LTC-300R and/or facility documentation shows a need exists for a possible Level II screen. The area nurse or nurse designee consults with OHCA staff as necessary.

(6) The area nurse or nurse designee, evaluates the UCAT, to determine if the applicant meets the medical eligibility criteria for NF level of care. Individuals may be medically-certified for NF level of care for various lengths of time depending on the client's needs. The area nurse or nurse designee, enters the medical eligibility decision and, when required, the medical certification review date into the electronic system within ten-business (10-business) days. A medical eligibility redetermination is not required when a client is discharged from the NF for a period not to exceed ninety-calendar (90-calendar) days and the original certification is current.

(7) When the OKDHS nurse recommends NF level of care and the client is determined by the area nurse or nurse designee, not to be medically eligible for NF level of care, the OKDHS nurse can submit additional information to the area nurse or nurse designee. When necessary, a visit by the OKDHS nurse to obtain additional information is initiated at the recommendation of the area nurse or nurse designee.

(8) Categorical relationship must be established for determination of eligibility for NF services. When categorical relationship to disability has not been established, the worker submits the same information, per OAC 317:35-5- 4(2), to the LOCEU to request a determination of eligibility for categorical relationship. LOCEU renders a decision on categorical relationship to the disabled applicant using the Social Security Administration (SSA) definition. A follow-up with the SSA by the OKDHS worker is required to ensure the SSA disability decision agrees with the LOCEU decision.

Okla. Admin. Code § 317:35-19-2

Added at 12 Ok Reg 753, eff 1-6-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3133, eff 7-27-95; Amended at 14 Ok Reg 56, eff 4-30-96 (emergency); Amended at 14 Ok Reg 1802, eff 5-27-97; Amended at 15 Ok Reg 3715, eff 5-28-98 (emergency); Amended at 16 Ok Reg 1438, eff 5-27-99; Amended at 17 Ok Reg 2410, eff 6-26-00; Amended at 20 Ok Reg 1958, eff 6-26-03; Amended at 21 Ok Reg 2252, eff 6-25-04

Amended by Oklahoma Register, Volume 34, Issue 23, August 15, 2017, eff. 9/1/2017

Amended by Oklahoma Register, Volume 36, Issue 21, July 15, 2019, eff. 9/1/2019

Amended by Oklahoma Register, Volume 41, Issue 23, August 15, 2024, eff. 9/1/2024