Medicaid – Medically Fragile Waiver

Purpose

The Medically Fragile Waiver provides services that allow Medicaid-eligible persons who need hospital and/or skilled nursing facility level of care to remain at home or in the residential setting of their choosing while receiving the necessary care. The Medically Fragile Program is a home and community-based alternative to placement in a hospital and/or skilled nursing facility to receive Medicaid-funded assistance for care. This waiver also incorporates self-direction opportunities for a specified group of services as a service delivery mechanism.

Contact

Eligibility

• Be at least 19 years of age;
• Meet hospital and/or skilled nursing level of care;
• Meet SoonerCare financial eligibility;
• Must be living at home or in a residential setting.

AT Services Provided/Covered

• Assessment for the need for 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

• Mobility/Seating & Positioning
• Environmental Adaptations

Application Process

•  Members work with their transition coordinator/case manager to determine the need for assistive technology services.

Dispute Resolution Process

1. The appeals process allows a member to appeal a decision involving medical services, prior authorizations for medical services, or discrimination complaints.
2. 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.
3. 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.
4. 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 member will continue to work with a Case Manager to update the service plan as the member’s needs change.
• The Medically Fragile Waiver provides medical/nursing services along with other home and community based services (i.e. housekeeping, meal prep, laundry) to members.
• Medically Fragile Waiver members have a Case Manager that assesses and monitors the member’s need for services and other life changes that may affect delivery of services.
• The annual cost of waiver services cannot exceed the aggregate average cost of providing care in a nursing/hospital facility. Services are approved and reimbursed by OHCA.
• The Medically Fragile Waiver offers participants self-directed services that provide the individual the opportunity to direct decisions regarding personal care services. Self-directed services enables the individuals with personal care needs the opportunity to recruit, hire, train, supervise, and when necessary, fire their personal care assistant. Participants are not required to utilize the self-directed service option.
• Any participant who no longer meets skilled nursing/hospital facility level of care may qualify for a State Plan or other community based services to meet their needs.