NURSING FACILITY TRANSITION SERVICES PROVIDER IN OKLAHOMA

SUPPORTING OKLAHOMANS IN RETURNING TO COMMUNITY LIVING FROM INSTITUTIONAL SETTINGS

Nursing Facility Transition Services in Oklahoma help individuals who reside in nursing homes or other institutional care settings move back into the community. These services assist with identifying housing, arranging supports, and securing one-time resources to ensure a safe and sustainable transition. Services are provided under Oklahoma Medicaid through the Living Choice program and Home and Community-Based Services (HCBS) waivers.

1. GOVERNING AGENCIES

Agency: Oklahoma Health Care Authority (OHCA

)Role: Oversees Medicaid (SoonerCare) and the Living Choice program, including provider enrollment, reimbursement, and service coordination.

Agency: Oklahoma Department of Human Services (OKDHS)**

Role: Coordinates transition-related case management, waiver services, and housing supports.

Agency: Centers for Medicare & Medicaid Services (CMS)**

Role: Provides federal oversight for Medicaid-funded transition initiatives under the Money Follows the Person (MFP) program.

2. NURSING FACILITY TRANSITION SERVICES OVERVIEW

These services help eligible individuals transition from a nursing facility to a home or community-based setting with the supports needed to live independently.

Approved providers may deliver:

• Transition Planning: Collaborative planning with the resident, facility, and waiver team to develop a discharge and support plan.

• Housing Navigation: Identifying affordable, accessible housing and securing lease agreements.

• One-Time Transition Expenses: Assisting with deposits, furniture, household items, and moving costs.

• Service Coordination: Arranging home and community-based services like personal care, transportation, and meals.

• Independent Living Skills Training: Budgeting, meal planning, medication self-management, and landlord communication.

• Post-Transition Monitoring: Follow-up visits to ensure a successful transition and service stability.

• Documentation: Transition planning forms, service logs, housing verification, and SoonerCare billing records.

3. LICENSING & PROVIDER APPROVAL REQUIREMENTS

Prerequisites:

• Register your business with the Oklahoma Secretary of State.

• Obtain EIN from the IRS and NPI (Type 2).

• Enroll as a SoonerCare provider through the Oklahoma Health Care Authority (OHCA).

• Apply for approval to provide Living Choice/Nursing Facility Transition Services under the designated waiver.

• Maintain general and professional liability insurance.

• Develop a Nursing Facility Transition Services Policy & Procedure Manual.

• Ensure staff meet required training standards and background check clearances.

4. OKLAHOMA PROVIDER ENROLLMENT PROCESS

Step 1: Business Setup

• Form a legal entity, obtain insurance, and complete required policy documentation.

Step 2: OHCA Enrollment

• Apply via the SoonerCare Provider Portal for participation in Living Choice or HCBS waiver services.

Step 3: Documentation Submission

• Submit credentialing materials, including staff qualifications, training logs, and readiness plans.

Step 4: Readiness Review

• OHCA or OKDHS may review your policies, forms, and readiness to serve transitioning residents.

Step 5: Approval & Service Authorization

• Upon approval, you may begin accepting referrals from facilities or case managers and begin billing SoonerCare.

5. REQUIRED DOCUMENTATION

• Articles of Incorporation or Business License

• IRS EIN and NPI confirmation

• Proof of general and professional liability insurance

• Transition Services Policy & Procedure Manual, including:

  • Transition planning workflows and assessment tools

  • Housing search and service linkage protocols

  • Participant rights and HIPAA compliance

  • One-time cost tracking and purchase logs

  • Staff credentialing, background checks, and orientation materials

  • Incident reporting and follow-up protocols

  • Medicaid billing documentation templates

6. STAFFING REQUIREMENTS

Role: Transition Coordinator

Requirements: Background in case management, social work, or home and community-based services; understanding of housing and Medicaid eligibility; background clearance.

Role: Independent Living Specialist (optional)**

Requirements: Experience in life skills coaching, community integration, and supporting individuals with disabilities.

All staff must complete:

• HIPAA and person-centered planning training

• SoonerCare documentation and service authorization processes

• Housing rights, landlord engagement, and fair housing compliance

• Emergency response and community safety training

7. MEDICAID WAIVER PROGRAMS & FUNDING STREAMS

Nursing Facility Transition Services in Oklahoma are covered under:

• Living Choice Program (Oklahoma’s Money Follows the Person initiative)

• ADvantage Waiver – for frail elders and adults with disabilities

• Medically Fragile Waiver

• In-Home Supports Waiver (for children and adults with IDD)

• State Plan Services (in conjunction with waiver eligibility)

8. TIMELINE TO LAUNCH

Phase: Business Registration & Policy Development

Timeline: 1–2 months

Phase: Staff Training & Medicaid Enrollment

Timeline: 2–3 months

Phase: Readiness Review & OHCA Certification

Timeline: 60–90 days

Phase: Launch & Referral Acceptance

Timeline: 30–45 days

9. CONTACT INFORMATION

Oklahoma Health Care Authority (OHCA)

Website: https://oklahoma.gov/ohca

Oklahoma Living Choice Program

Website: https://oklahoma.gov/ohca/individuals/programs/living-choice.html

Oklahoma Department of Human Services (OKDHS)

Website: https://oklahoma.gov/okdhs

Centers for Medicare & Medicaid Services (CMS)

Website: https://www.cms.gov

WAIVER CONSULTING GROUP’S START-UP ASSISTANCE SERVICE — OKLAHOMA NURSING FACILITY TRANSITION SERVICES PROVIDER

WCG helps providers establish Medicaid-compliant transition services in Oklahoma with:

Scope of Work:

• Business formation, OHCA enrollment, and Living Choice program application

• Policy manual development for housing transition and service coordination

• Staff training tools, service tracking templates, and billing documentation

• Referral outreach materials for nursing homes, social workers, and waiver teams

• Quality assurance systems and transition stability tracking

• Coordination tools for connecting to housing authorities and HCBS service providers

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