Current through Vol. 42, No. 1, September 16, 2024
(a)
Applicability. This Section
applies to services funded through Medicaid HCBS Waivers, per Oklahoma
Administrative Code (OAC)
317:35-9-5, and Section 1915(c)
of the Social Security Act. Specific Waivers include service recipients who
receive:
(1) daily living supports, per OAC
317:40-5-150; or
(2) group home services, per OAC
317:40-5-152.
(b)
General Information. In an
effort to support participation in community life Oklahoma Human Services
Developmental Disabilities Services (DDS) may supplement room and board costs
for service recipients with income insufficient to meet the costs of the items
listed in (b)(1)(A) through (H). Room and board costs are not a reimbursable
waiver expense, per the HCBS service regulations. The provider may request a
supplemental room and board payment when room and board expenses in a
residential setting exceeds income. DDS State Fund supplemental payments permit
a provider to be reimbursed for room and board costs beyond a service
recipient's ability to pay with personal benefits income.
(1) Allowable room and board costs are actual
monthly expenses that include:
(A)
rent;
(B) food;
(C) housing supplies;
(D) utilities;
(E) basic cable or television;
(F) telephone;
(G) repair and maintenance that are not an
obligation of another entity; and
(H) insurance.
(2) Room and board reimbursement is
authorized, per OAC 340-3-33.1. When the need for a supplemental payment is
expected to continue, cost effective community living arrangements are
considered and documented in the Individual Plan. The supplemental room and
board payment must meet all of the requirements in (A) through (E) of this
paragraph.
(A) Funding to meet the service
recipient's needs are not available through another source.
(B) The service recipient's room and board
expenses are consistent with fair market values for properties in the general
area.
(C) The supplemental payment
must be necessary to support community living and must be required for other
than the preference of the service recipient, family, or provider.
(D) The provider must provide detailed
expenses including but not limited to mortgage detail and status. The mortgage
may not be a loan with business debt that is greater than the properties fair
market value or non-routine costs for non-physical plant excluding the normal
escrow items such as taxes and insurance.
(E) The provider must disclose common
ownership interests between the provider and mortgage holder or
lessor.
(3) The service
recipient's Personal Support Team (Team) ensures individuals have a minimum of
$100 of personal spending money each month unless the DDS director or designee
approves a lesser amount.
(4) When
possible, the Team develops a plan to resolve the room and board deficiency by
identifying lower cost housing options or seeking roommates when there are
additional bedrooms available.
(c)
Room and board payment. Each
service recipient contributes an amount the provider determines, not to exceed
actual expenses. The service recipient retains at least $100 a month in
personal spending money. The service recipient contributes employment income to
meet his or her room and board costs.
(1) To
ensure Waiver funding is not used for room and board costs when the service
recipient has exceptionally low income, a room and board supplement is
provided. The supplement is provided when he or she:
(A) does not have adequate income to meet his
or her room and board expenses;
(B)
is awaiting a medical decision from the Social Security Administration for
Supplemental Security income eligibility; or
(C) is unable to achieve sustained employment
resulting in a room and board income deficit.
(2) Each month the provider submits:
(A) OKDHS Form 06CL001E, Room and Board
Supplement Claim Form, for reimbursement within three-months of the last date
of service;
(B) an invoice with:
(i) the date of service;
(ii) a unique invoice number;
(iii) an itemized description of services and
total amount that matches Form 06CL001E; and
(iv) name and address of the vendor that
matches the contract name and address.
(3) Proof of payment for all claim
expenditures is included.
(d)
Provider requirements. The
provider establishes a written financial agreement with the service recipient
or legal guardian that defines the provider and service recipient's
responsibilities, per OAC
340:100-5-22.1.
(1) The provider ensures:
(A) service recipient expenses accrue on a
monthly basis and are actual expenses;
(B) the Social Security Administration is
contacted to review the service recipient's benefits when his or her personal
benefits are low; and
(C) the
service recipient is employed an average of 30 hours per week. When the service
recipient does not participate in 30 hours per week of employment services, the
Team develops a plan to address the situation, per OAC
317:40-7-15.
(2) The provider notifies the DDS case
manager when the service recipient's room and board, income, or expenditures
change significantly.
(e)
Service recipient requirements. DDS may request that the service
recipient reimburse OKDHS for the approved room and board expenses when he or
she receives a Social Security Disability Benefits back payment. DDS may
request reimbursement when:
(1) making the
requested reimbursement does not cause the service recipient to be in debt;
and
(2) the service recipient or
his or her legal guardian completes OKDHS Form 06AD010E, Service Recipient Room
and Board Reimbursement.
