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Part 113      LIVING CHOICE PROGRAM

317:30-5-1200.Benefits for members age 65 or older with disabilities or long-term illnesses

[Revised 07-01-13]

(a) Living Choice program participants age 65 or older with disabilities or long-term illnesses may receive a range of necessary medical and home and community based services for one year after moving from an institutional setting.  The one year period begins the day the member occupies a qualified residence in the community.  Once this transition period is complete, the member receives services through one of the Opportunities for Living Life home and community based services waivers.

(b) Services must be billed using the appropriate HCPCS or CPT codes and must be medically necessary.

(c) All services must be necessary for the individual to live in the community, require prior authorization, and must be documented in the individual transition plan.  The number of units of services the member is eligible to receive is limited to the amounts approved in the transition plan.

(d) Services that may be provided through the Living Choice program for older persons with disabilities or long-term illnesses are listed in paragraphs (1) through (26) of this subsection:

(1) case management;

(2) respite care;

(3) adult day health care;

(4) environmental modifications;

(5) specialized medical equipment and supplies;

(6) therapy services including physical, occupational, speech and respiratory;

(7) advanced supportive/restorative assistance;

(8) skilled nursing;

(9) extended duty nursing;

(10) home delivered meals;

(11) hospice care;

(12) medically necessary prescription drugs;

(13) personal care as described in Part 95 of this Chapter;

(14) Personal Emergency Response System (PERS);

(15) self-direction;

(16) transition coordination;

(17) community transition services as described in OAC 317:30-5-1205;

(18) dental services (up to $1,000 per person annually);

(19) nutrition evaluation and education services;

(20) agency companion services;

(21) pharmacological evaluations;

(22) vision services including eye examinations and eyeglasses;

(23) non-emergency transportation;

(24) family training services;

(25) assisted living services; and

(26) SoonerCare compensable medical services.

317:30-5-1201.Benefits for members with mental retardation
[Revised 06-25-12]
(a) Living Choice program participants with intellectual disabilities may receive a range of necessary medical and home and community based services for one year after moving from the institution. The one year period begins the day the member occupies a qualified residence in the community. Once this transition period is complete, the member receives services through the Community waiver.
(b) Services must be billed using the appropriate HCPCS or CPT codes and must be medically necessary.
(c) All services must be necessary for the individual to live in the community, require prior authorization, and must be documented in the individual transition plan. The number of units of services the member is eligible to receive is limited to the amounts approved in the transition plan. The transition plan may be amended as the member's needs change.
(d) Services that may be provided to members with intellectual disabilities are listed in paragraphs (1) through (28) of this subsection:
(1) assistive technology;
(2) adult day health care;
(3) architectural modifications;
(4) audiology evaluation and treatment;
(5) community transition;
(6) daily living support;
(7) dental services;
(8) family counseling;
(9) family training;
(10) group home;
(11) respite care;
(12) homemaker services;
(13) habilitation training services;
(14) home health care;
(15) intensive personal support;
(16) extended duty nursing;
(17) skilled nursing;
(18) nutrition services;
(19) therapy services including physical, occupational, and speech;
(20) psychiatry services;
(21) psychological services;
(22) agency companion services;
(23) non-emergency transportation;
(24) pre-vocational services;
(25) supported employment services;
(26) specialized foster care;
(27) specialized medical equipment and supplies; and
(28) SoonerCare compensable medical services.
317:30-5-1202.Benefits for members with physical disabilities

[Revised 07-01-13]

(a) Living Choice program participants with physical disabilities may receive a range of necessary medical and home and community based services for one year after moving from the institution.  The one year period begins the day the member occupies a qualified residence in the community.  Once this transition period is complete, the member receives services through one of the Opportunities for Living Life home and community based services waivers.

(b) Services must be billed using the appropriate HCPCS or CPT codes and must be medically necessary.

(c) All services must be necessary for the individual to live in the community, require prior authorization, and must be documented in the individual transition plan.  The number of units of services the member is eligible to receive is limited to the amounts approved in the transition plan.

(d) Services that may be provided to members with physical disabilities are listed in paragraphs (1) through (32) of this subsection:

(1) case management;

(2) personal care services as described in Part 95 of this Chapter;

(3) respite care;

(4) adult day health care with personal care and therapy enhancements;

(5) architectural modifications;

(6) specialized medical equipment and supplies;

(7) advanced supportive/restorative assistance;

(8) skilled nursing;

(9) home delivered meals;

(10) therapy services including physical, occupational, speech and respiratory;

(11) hospice care;

(12) Personal Emergency Response System (PERS);

(13) Self-Direction;

(14) agency companion services;

(15) extended duty nursing;

(16) psychological services;

(17) audiology treatment and evaluation;

(18) non-emergency transportation;

(19) assistive technology;

(20) dental services (up to $1,000 per person annually);

(21) vision services including eye examinations and eyeglasses;

(22) pharmacotherapy management;

(23) independent living skills training;

(24) nutrition services;

(25) family counseling;

(26) family training;

(27) transition coordination;

(28) psychiatry services;

(29) community transition services as described in OAC 317:30-5-1205;

(30) pharmacological evaluations;

(31) assisted living services; and

   (32) SoonerCare compensable medical services.

317:30-5-1203.Billing procedures for Living Choice services

[Revised 07-01-13]

(a) The approved individual transition plan is the medical basis for services and includes the prior authorizations, specifying:

(1) the service;

(2) the service provider;

(3) the number of units authorized; and

(4) the authorized begin and end dates of the service.

(b) Institution Transition Case Management services are billed per 15-minute unit of service using the appropriate HCPC and modifier associated with the location of residence of the member served.  A unique modifier code is used to distinguish Institution Transition Case Management services from regular Case Management services.  The services are billed effective the date of transition into Living Choice and the provider records document actual time and date of services provided.

(c) As part of Living Choice quality assurance, audits are used to evaluate whether claims are consistent with individual transition plans and services provided are documented.  Claims that are not supported by individual transition plans and/or documentation of services are referred to the Program Integrity unit.  Erroneous or invalidated claims identified through post payment reviews are recouped from the provider.

(d) Claims may not be filed until the services are rendered.

317:30-5-1204.Disclosure of information on health care providers and contractors
[Issued 12-01-08]
In accordance with the requirements of the Social Security Act and the regulations issued by the Secretary of Health and Human Services, the OHCA is responsible for disclosure of pertinent findings resulting from surveys made to determine eligibility of certain providers for home health care and contractors under SoonerCare. The Oklahoma State Department of Health (OSDH) is responsible for surveying home health care providers and contractors to obtain information for use by the Federal Government in determining whether these entities meet the standards required for participation as Medicare and SoonerCare providers.
317:30-5-1205.Community transition services
[Issued 12-01-08]
(a) Community transition services are one-time set-up expenses for members who transition from a nursing facility or public ICF/MR to a home in the community.
(b) Each member who transitions into the community is eligible for up to $2,400 per person for the purchase of essential goods and/or services authorized by a transition coordinator on the member's behalf.
(c) Community transition services must be reasonable and necessary as determined through the transition plan development process and must be clearly identified in the plan.
(d) Allowable expenses for community transition services include, but are not limited to:
(1) security deposits that are required to obtain a lease on a qualified residence;
(2) essential household items required for occupation and use in a community residence such as furniture, window coverings, food preparation and bed/bath linens;
(3) connection, set-up fees or deposits for utility service or access including telephone, electricity, heating and water;
(4) services necessary for the member's health, safety and welfare such as pest eradication and one-time cleaning prior to occupancy;
(5) moving expenses;
(6) fees to obtain a copy of birth certificate, identification card or driver's license; and
(7) delivery, set-up costs and removal fees for appliances, furniture, etc.
(e) Non-allowable expenses for community transition services include, but are not limited to:
(1) monthly rental or mortgage expenses;
(2) monthly utility charges;
(3) household items that are purely for recreational purposes; and
(4) services or items that are available through other Living Choice services such as homemaker services, environmental modifications and adaptations, or specialized supplies and equipment.
317:30-5-1206.Transition coordinator services
[Issued 12-01-08]
Transition coordinators must meet the requirements in paragraphs (1) and (2) of this subsection.
(1) Transition coordinators must:
(A) complete case management training with the ADvantage waiver; or
(B) complete the curriculum requirements for a bachelor's degree and one year paid professional experience in aging or disability populations; or
(C) complete a degree program as a registered nurse or licensed practice nurse and one year paid professional experience; or
(D) have at least two years paid work experience as an independent living specialist or transition specialist at one of the five federally recognized Centers for Independent Living organizations in Oklahoma.
(2) Transition coordinators must successfully complete the Living Choice program transition coordinator training.
317:30-5-1207.Benefits for members ages sixteen (16) through eighteen (18) in a psychiatric residential treatment facility

[Revised 09-14-18]

(a) Living Choice program participants, ages sixteen (16) through eighteen (18), may receive a range of necessary home and community based services for one year after transitioning to the community from a psychiatric residential treatment facility (PRTF) setting. In order to be eligible for the Living Choice program, the member must:

(1) Have been in a PRTF facility for ninety (90) or more days during an episode of care; and

(2) Meet Level 3 criteria on the Individual Client Assessment Record; or

(3) Meet the criteria for Serious Emotional Disturbance as defined in OAC 317:30-5-240.1; or 

(4) Show critical impairment on a caregiver rated Ohio Scales (score of 25 and above on the Problems Subscale or a score of 44 and below on the Functioning Subscales).

(b) Services must be billed using the appropriate Healthcare Common Procedure Code System and must be medically necessary.

(c) All services must be necessary for the individual to live successfully in the community, must be documented in the individual care plan and require prior authorization.

(d) Services that may be provided to members transitioning from a PRTF are found in OAC 317:30-5-252.

(e) Reimbursement will be for a monthly care coordination payment upon successful submission of a claim for one or more of the covered services listed in OAC 317:30-5-252.

 

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.