Current through Vol. 42, No. 1, September 16, 2024
(a) Rates for Waiver services are set in
accordance with the rate-setting process by the State Plan Amendment and Rate
Committee (SPARC) and approved by the Oklahoma Health Care Authority(OHCA)
Board.
(1) The rate for Nursing Facility (NF)
respite is set equivalent to the rate for routine level of care NF services
that require providers having equivalent qualifications;
(2) The rate for daily units for Adult Day
Health is set equivalent to the rate established by the Oklahoma Department of
Human Services (OKDHS) for equivalent services provided for the OKDHS Adult Day
Service Program that requires providers have equivalent
qualifications.
(3) The rate for
units of home-delivered meals is set equivalent to the rate established by the
OKDHS for the equivalent services provided for the OKDHS Home-Delivered Meals
Program that require providers having equivalent qualifications.
(4) The rates for units of ADvantage Personal
Care and In-Home Respite are set equivalent to State Plan Agency Personal Care
unit rate that requires providers have equivalent qualifications.
(5) The rates for Advanced
Supportive/Restorative Assistance is set equivalent to 1.077 of the State Plan
Agency Personal Care unit rate;
(6) Consumer-Directed Personal Assistance
Services and Supports (CD-PASS) rates are determined using the Individual
Budget Allocation (IBA) Expenditure Accounts Determination process for each
member. The IBA Expenditure Accounts Determination process includes
consideration and decisions about the items listed in (A) B (C) of this
paragraph.
(A) The IBA Expenditure Accounts
Determination constrains total Medicaid reimbursement for CD-PASS services to
be less than expenditures for equivalent services using agency providers.
(B) The Personal Care (PSA) and
Personal Care Advanced Supportive/Restorative (APSA) service unit rates are
calculated by the OKDHS Aging Services (AS) during the CD-PASS service
eligibility determination process. OKDHS AS sets the PSA and APSA unit rates at
a level that is not less than eighty percent(80%) and not more than ninety-five
percent(95%) of the comparable PSA or APSA service rates. The allocation of
portions of the PSA and/or APSA rates to cover salary, mandatory taxes, and
optional benefits including Worker's Compensation insurance, when available, is
determined individually for each member using the CD-PASS IBA Expenditure
Accounts Determination Process.
(C)
The IBA Expenditure Accounts Determination process defines the level of program
financial resources required to meet the member's need for CD-PASS services.
When the member's need for services changes due to a change in
health/disability status or a change in the level of support available from
other sources to meet needs, the case manager, based upon an updated
assessment, amends the person-centered service plan to increase CD-PASS service
units appropriate to meet additional member need. OKDHS AS, upon favorable
review, authorizes the amended person-centered service plan and updates the
member's IBA. Service amendments based on changes in member need for services
do not change an existing PSA or APSA rate. The member with assistance from the
Financial Management Service, reviews and revises the IBA Expenditure Accounts
calculation annually or more often to the extent appropriate and
necessary.
(7) Three (3)
per diem reimbursement rate levels for the ADvantage assisted living services
are set. Different rate per diem levels are established to adequately reimburse
the provider for the provision of different levels of service to accommodate
different level of member need for services-type, intensity and frequency to
address member Activities of Daily Living and Instrumental Activities of Daily
Living (ADL/IADL) and health care needs. Rounded to the nearest cent, the
lowest level Assisted Living Services per diem rate is set equivalent to 11.636
times the State Plan Agency Personal Care unit rate; the mid-level per diem
rate is set equivalent to 15.702 times the State Plan Agency Personal Care unit
rate; and the highest level Assisted Living Services per diem rate is set
equivalent to 21.964 times the State Plan Agency Personal Care unit rate. The
specific rate level appropriate to a particular member's service is determined
by Uniform Comprehensive Assessment Tool, Part III (UCAT III) assessment by the
member's Advantage case manager employed by a case management agency
independent of the Assisted Living Services provider. ADvantage payment is not
made for twenty-four (24) hour skilled care in an assisted living center.
Federal financial participation is not available for room and board, items of
comfort or convenience, or the costs of facility maintenance, upkeep and
improvement. Separate payment is not made for ADvantage services of personal
care, advanced supportive/restorative assistance, skilled nursing, Personal
Emergency Response System, home-delivered meals, adult day health or
environmental modifications to a member while receiving assisted living
services since these services are integral to and inherent in the provision of
assisted living service. However, separate payment may be made for Medicaid
State Plan and/or Medicare Home Health benefits to members receiving ADvantage
assisted living. Separate payment is not made for ADvantage respite to a member
while receiving assisted living services since by definition assisted living
services assume the responsibility for twenty-four (24) hour
oversight/monitoring of the member, eliminating the need for informal support
respite. The member is responsible for room and board costs; however, for an
ADvantage member, the ADvantage assisted living services provider is allowed to
charge a maximum for room and board that is no more than ninety (90) percent of
the Supplemental Security Income (SSI) Federal Benefit Rate. When, per Oklahoma
Administrative Code (OAC)
317:35-17-1(b)
and
317:35-17-11,
the member has a vendor payment obligation, the provider is responsible for
collecting the vendor payment from the member.
(8) The maximum total annual reimbursement
for a member's hospice care within a twelve (12) month period is limited to an
amount equivalent to eighty-five (85) percent of the Medicare Hospice Cap
payment.
(b) The OKDHS
AS approved ADvantage person-centered service plan is the basis for the
Medicaid Management Information Systems (MMIS) service prior authorization,
specifying the:
(1) Service;
(2) Service provider;
(3) Units authorized; and
(4) Begin and end dates of service
authorization.
(c)
Service time for personal care, case management services, nursing, skilled
nursing, supportive/restorative assistance, and in-home respite, is documented
through the use of thedesignated statewide Electronic Visit Verification System
(EVV) when services are provided in the home. Providers are required to use the
EVV system after access to the system is made available by OKDHS. Refer to OAC
317:30-3-34(7) for additional procedures for EVV system failure or EVV system
unavailability.
(d) As part of
ADvantage quality assurance, provider audits evaluate whether paid claims are
consistent with service plan authorizations and documentation of service
provision. Evidence of paid claims not supported by service plan authorization
and documentation of service provisions are given to OHCA's Program Integrity
Unit for follow-up investigation.
Added at 12 Ok Reg 751, eff 1-5-95 through 7-14-95
(emergency); Added at 12 Ok Reg 3131, eff 7-27-95 ; Amended at 18 Ok Reg 2962,
eff 5-17-01 (emergency); Amended at 19 Ok Reg 337, eff 11-14-01 (emergency);
Amended at 19 Ok Reg 1067, eff 5-13-02 ; Amended at 20 Ok Reg 374, eff 1-1-03
(emergency); Amended at 20 Ok Reg 1920, eff 6-26-03 ; Amended at 22 Ok Reg
2731, eff 5-4-05 (emergency); Amended at 23 Ok Reg 1366, eff 5-25-06 ; Amended
at 24 Ok Reg 83, eff 8-2-06 (emergency); Amended at 24 Ok Reg 932, eff 5-11-07
; Amended at 25 Ok Reg 660, eff 2-1-08 through 7-14-08 (emergency)
1 ; Amended at 25 Ok Reg 2685, eff
7-25-08 ; Amended at 26 Ok Reg 994, eff 5-1-09 (emergency); Amended at 27 Ok
Reg 621, eff 1-14-10 (emergency); Amended at 27 Ok Reg 1466, eff 6-11-10 ;
Amended at 30 Ok Reg 1179, eff 7-1-13
1 This emergency action
expired on 7-14-08 before being superseded by a permanent action. Upon
expiration of an emergency amendatory action, the last effective permanent text
is reinstated. Therefore, on 7-15-08 (after the 7-14-08 expiration of the
emergency action), the text of 317:30-5-764 reverted back to the permanent text
that became effective 5-11-07, as was last published in the 2007 OAC
Supplement, and remained as such until amended again by permanent action on
7-25-08.
