Okla. Admin. Code § 317:35-17-19 - Closure or termination of ADvantage services
(a)
Voluntary closure of ADvantage
services. When the member requests a lower level of care than ADvantage
services, or agrees that ADvantage services are no longer needed to meet his or
her needs, a medical level of care decision by the area nurse or nurse
designee, is not needed. The closure request is completed and signed by the
member and the ADvantage case manager and sent to the ADvantage Administration
(AA) to be placed in the member's case record. The AA notifies the Oklahoma
Department of Human Services (DHS) area nurse or area nurse designee of the
voluntary closure and effective date of closure. When the member's written
request for closure cannot be secured, the ADvantage case manager documents in
the member's case record the reasons for the voluntary termination of services
and alternatives for services.
(b)
Closure due to financial or medical ineligibility. The process for
closure due to financial or medical ineligibility is described in this
subsection.
(1)
Financial
ineligibility. When the local DHS office determines a member does not
meet financial eligibility criteria, the DHS office notifies the area nurse or
area nurse designee who closes the member's authorization and notifies the
member and AA of financial ineligibility by system-generated mail. The AA
notifies the member's providers of the decision. A medical eligibility
redetermination is not required when a financial ineligibility period does not
exceed the medical certification period.
(2)
Medical ineligibility. When
the DHS office is notified by the nurse or area nurse designee of a decision
that the member is no longer medically eligible for ADvantage services, the DHS
office notifies the member and AA of the decision. Refer to Oklahoma
Administrative Code (OAC)
317:35-17-16(d).
The AA notifies the member's providers of the decision.
(c)
Closure due to other
reasons. Refer to OAC
317:35-17-3(e)
- (h).
(d)
Resumption of
ADvantage services. When a member approved for ADvantage services is
without services for less than ninety (90) calendar days and has a current
medical and financial eligibility determination, services may be resumed using
the previous authorized person-centered service plan. When a member requests to
have his or her services restarted after ninety (90) calendar days, the member
must request a new referral for services through the DHS county office or AA.
When a member is determined eligible for ADvantage services and transistions
from a hospital or a nursing facility to a community setting, an ADvantage case
manager may provide Institution Transition case management services to assist
the member to establish or re-establish him or herself safely in the
home.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(a) Voluntary closure of ADvantage services. When the member requests a lower level of care than ADvantage services, or agrees that ADvantage services are no longer needed to meet his or her needs, a medical level of care decision by the area nurse or nurse designee, is not needed. The closure request is completed and signed by the member and the ADvantage case manager and sent to the ADvantage Administration (AA) to be placed in the member's case record. The AA notifies the Oklahoma Department of Human Services (DHS) area nurse or area nurse designee of the voluntary closure and effective date of closure. When the member's written request for closure cannot be secured, the ADvantage case manager documents in the member's case record the reasons for the voluntary termination of services and alternatives for services.
(b) Closure due to financial or medical ineligibility. The process for closure due to financial or medical ineligibility is described in this subsection.
(1) Financial ineligibility. When the local DHS office determines a member does not meet financial eligibility criteria, the DHS office notifies the area nurse or area nurse designee who closes the member's authorization and notifies the member and AA of financial ineligibility by system-generated mail. The AA notifies the member's providers of the decision. A medical eligibility redetermination is not required when a financial ineligibility period does not exceed the medical certification period.
(2) Medical ineligibility. When the DHS office is notified by the nurse or area nurse designee of a decision that the member is no longer medically eligible for ADvantage services, the DHS office notifies the member and AA of the decision. Refer to Oklahoma Administrative Code (OAC) 317:35-17-16(d). The AA notifies the member's providers of the decision.
(c) Closure due to other reasons. Refer to OAC 317:35-17-3(e) - (h).
(d) Resumption of ADvantage services. When a member approved for ADvantage services is without services for less than ninety (90) calendar days and has a current medical and financial eligibility determination, services may be resumed using the previous authorized person-centered service plan. When a member requests to have his or her services restarted after ninety (90) calendar days, the member must request a new referral for services through the DHS county office or AA. When a member is determined eligible for ADvantage services and transistions from a hospital or a nursing facility to a community setting, an ADvantage case manager may provide Institution Transition case management services to assist the member to establish or re-establish him or herself safely in the home.