Medicaid - Living Choice Demonstration
Oklahoma Living Choice Project
Oklahoma Health Care Authority
The Oklahoma Living Choice Demonstration promotes community living for people of all ages who have disabilities or long-term illnesses. The project gives Oklahomans more options for managing their health care needs and adding more balance to the state’s long-term care system. With grant funding from the Centers for Medicare & Medicaid Services (CMS) under the Money Follows the Person Rebalancing Demonstration, the Oklahoma Health Care Authority (OHCA) will help individuals transition into their own homes in the community.
Joseph Mecham, Operations Director
Oklahoma Health Care Authority
2401 NW 23rd, Ste 1A
Oklahoma City, OK 73107
- Individuals must be determined eligible for SoonerCare for at least one day prior to transition from a nursing home/institution;
- be at least 19 years of age;
- must have lived in the institutional setting for 90 consecutive days prior to transition;
- the individual wants to transition back into the community;
- be able to live safely in the community; and
- be willing to play an active role in his or her plan of care.
AT SERVICES PROVIDED/COVERED
- Assessment for the need of assistive technology/auxiliary aids
- Training the service recipient/provider in the use and maintenance of equipment/auxiliary aids
- Repair of adaptive devices
AT DEVICES PROVIDED/COVERED
- Aids for Daily Living
- Speech Communication
- Aids for Hearing Impaired
- Environmental Adaptations
- Aids for Vision Impaired
- Mobility/Seating & Positioning
- A referral is made to the Oklahoma Health Care Authority (OHCA) Living Choice Project staff by calling (888) 287-2443 to complete an intake by telephone.
- DDSD staff will refer individuals currently residing in either Northern Oklahoma Resource Center (NORCE) or Southern Oklahoma Resource Center (SORC) to contracted community providers that will participate in the transition planning. Individuals transitioning out of NORCE or SORC are exempt from the intake, assessment and eligibility process.
- Formal and informal assessments will be conducted to determine transition feasibility. A Living Choice Common Intake form will be completed.
- Once eligibility and assessment indicates the individual qualifies for transition, the OHCA ensures that a written Individual Transition Plan will be developed by the individual and their transition team.
- The Individual Transition Plan will include the needed services, who will provide the services and the goals to outline the expected duration of each service.
- The appeals process allows a member to appeal a decision involving medical services, prior authorizations for medical services, or discrimination complaints.
- In order to file an appeal, the member files a LD-1 form within 20 days of the triggering event. The triggering event occurs at the time when the member knew or should have known of such condition or circumstance for appeal. The staff advises the Appellant that if there is a need for assistance in reading or completing the grievance form, arrangements will be made.
- If the LD-1 form is not received within 20 days of the triggering event or if the form is not completely filled out with all necessary documentation, OHCA sends the Appellant a letter stating the appeal will not be heard.
- Upon receipt of the member’s appeal, a fair hearing before the Administrative Law Judge (ALJ) will be scheduled. The member will be notified in writing of the date and time for this procedure. The member must appear at this hearing. The ALJ’s decision may be appealed to the CEO, which is a record review at which the parties do not appear.
PIECES OF THE PUZZLE
- Each participant will work with a transition coordinator and a transition planning team to complete a transition plan to meet the person’s needs.
- The individual selects from a list of available providers. Providers contract with SoonerCare as an agreement to provide services.
- This waiver is to assist with resources that would allow an eligible individual the ability to move out of the nursing home or institution. Funds from Living Choice Demonstration Waiver may be used for home establishment services such as housing deposits, furniture, and utility deposits that are not typically purchased for individuals without services from a Home and Community-Based Waiver.
- The Living Choice Demonstration Waiver provides medical services along with home and community based services to individuals during their first year of community living. At the end of the 12 month period the individual will then move into the My Life; My Choice Waiver (p. 37) or if they are 65 years or older the Sooner Seniors Waiver (p. 39). Individuals that have transitioned out of NORCE or SORC will transition into the Community Based waiver (p. 29) on day 366.
- Because the individual plan of care costs are limited in the ADvantage Waiver, adults with physical disabilities may need additional assistance to remain in the community. Some of the services include: case management, respite, environmental modifications, specialized medical equipment and supplies, physical therapy, occupational therapy, respiratory therapy, speech therapy, skilled nursing, and personal care services from the Medicaid State Plan or the Medically Fragile Waiver.
- The annual cost of services cannot exceed the aggregate average cost of a nursing home. Services are approved and reimbursed by OHCA. There is no co-payment or deductible.
- Living Choice participants have a transition coordinator/case manager that monitors the participants transition plan at least monthly. Living Choice also utilizes a quality improvement strategy where staff members conduct provider audits and survey satisfaction on provider retrospective claims reviews.
- The Living Choice Demonstration Waiver will soon offer participants that are 19 years of age and older that have a physical disability or long-term illness self-directed services. Those services will provide the individual the opportunity to direct decisions regarding personal care services. Self-directed services enable participants that have personal care assistance needs to recruit, hire, train, supervise, and when necessary, fire their personal care attendant. Participants are not required to utilize the Self-Directed Service option.