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317:30-5-761.Eligible providers

[Revised 09-01-19]

ADvantage Program service providers, except pharmacy providers, must be certified by the ADvantage Program ADvantage Administration (AA) and must have a current signed SoonerCare (Medicaid) contract on file with the Oklahoma Health Care Authority (OHCA), the State Medicaid agency.

(1) The provider programmatic-certification process must verify the provider meets licensure, certification and training standards as specified in the waiver document and agrees to ADvantage Program Conditions of Participation. Providers must obtain programmatic-certification to be ADvantage program certified.

(2) The provider financial-certification process must verify that the provider uses sound business management practices and has a financially-stable business. All providers, except for nursing facility (NF) respite, medical equipment and supplies, and environmental modification providers, must obtain financial certification to be ADvantage program certified.

(3) Providers may fail to gain or may lose ADvantage program certification due to failure to meet programmatic or financial standards.

(4) At a minimum, provider financial certification is reevaluated annually.

(5) The Oklahoma Department of Human Services (DHS) Aging Services (AS) evaluates adult day health and home-delivered meal providers for compliance with ADvantage programmatic-certification requirements. When an adult day health or home-delivered meal provider does not have a contract with AS, the provider must obtain programmatic certification to be ADvantage Program certified.  Providers of medical equipment and supplies, environmental modification, personal emergency response systems, hospice, Consumer-Directed Personal Assistance Services and Supports (CD-PASS), and NF respite services do not have a programmatic evaluation after the initial certification.

(6) DHS AS does not authorize an active power of attorney of a member to be the member's CD-PASS services provider.

(7) DHS AS may authorize a member's legally-responsible spouse or legal guardian to be SoonerCare (Medicaid) reimbursed, per 1915(c) ADvantage Program as a personal care, service provider. Authorization for a spouse or legal guardian as a provider requires the criteria in (A) through (D) and monitoring provisions to be met.

(A) Authorization for a spouse or legal guardian to be the care provider for a member may occur only when the member is offered a choice of providers and documentation demonstrates:

(i) no provider included on the Certified Agency Report (CAR) has available staffing; This is as evidenced by supportive documentation, which affirms no provider within the members service area can staff and all area providers attempt to employ staff to serve; or

(ii) the member's needs are so complex that unless the spouse or legal guardian provides the care, the member's risk level would increase; and

(iii) it is mentally or physically detrimental for someone other than the spouse or legal guardian to provide care. This is evidenced by the documentation from a qualified clinician or medical provider such as a physician or licensed psychologist.

(B) The service must:

(i) meet the definition of a service/support as outlined in the federally-approved waiver document;

(ii) be necessary to avoid institutionalization;

(iii) be a service/support specified in the person-centered service plan;

(iv) be provided by a person who meets the provider qualifications and training standards specified in the waiver for that service;

(v) be paid at a rate that does not exceed that which would otherwise be paid to a provider of a similar service and does not exceed what is allowed by OHCA for the payment of personal care or personal assistance services; and

(vi) not be an activity the spouse or legal guardian would ordinarily perform or is responsible to perform.

(C) The spouse or legal guardian service provider complies with:

(i) providing no more than forty (40) hours of services in a seven-day (7-day) period;

(ii) planned work schedules that must be available in advance for the member's case manager, and variations to the schedule must be noted and supplied to the case manager two (2) weeks in advance unless the change is due to an emergency;

(iii) maintaining and submitting time sheets and other required documentation for hours paid; and

(iv) the person-centered service plan as the member's care provider.

(D) In addition to case management, monitoring, and reporting activities required for all waiver services, the State is obligated to additional monitoring requirements when members elect to use a spouse or legal guardian as a paid service provider.  The AA monitors, through quarterly documentation submitted by the case manager, the continued appropriateness of the policy exception that allows the spouse or legal guardian to serve as the member's paid caregiver.

(8) Providers of durable medical equipment and supplies must comply with Oklahoma Administrative Code 317:30-5-210(2) regarding proof of delivery for items shipped to the member's residence.

(9) DHS AS periodically performs a programmatic audit of adult day health, assisted living, case management, home care (providers of skilled nursing, personal care, in-home respite, and advanced supportive/restorative assistance and therapy services) and CD-PASS providers. When due to a programmatic audit, a provider Plan of Correction (POC) is required, the AA may stop new cases and referrals to the provider until the (POC) is approved, implemented, and follow-up review occurs.  Depending on the nature and severity of problems discovered during a programmatic audit and at the discretion of the DHS AS, members determined to be at risk for health or safety may be transferred from a provider requiring a POC to another provider.

 

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.