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Part 95      AGENCY PERSONAL CARE SERVICES

317:30-5-950.Eligible providers

[Revised 09-14-18]
   Reimbursement for personal care is made only to agencies that are certified as home care agency providers by the Oklahoma State Department of Health and are certified by the ADvantage Administration (AA) as meeting applicable federal, state and local laws, rules and regulations. In order to be eligible for reimbursement, the home care agency must have an approved provider agreement on file with the Oklahoma Health Care Authority (OHCA), per Oklahoma Administrative Code (OAC) 317:30-30-3-2.  Service time of personal care is documented solely through the Electronic Visit Verification (EVV) system when services are provided in the member's home. The home care agency is required to use the EVV system. The EVV system provides alternate backup solutions when the automated system is unavailable. In the event of EVV backup system failure, the provider documents the time in accordance with their agency backup plan. The agency's backup procedures are only permitted when the EVV system is unavailable. Refer to OAC 317:35-17-22 for additional instructions.

317:30-5-951.Coverage by category
[Revised 8-02-06]
SoonerCare payment is made to agencies, on behalf of SoonerCare members, for personal care services (PC services) provided in the member's home. Personal Care services may be provided in an educational or employment setting to assist the member in achieving vocational goals identified on an approved care plan. Personal care services prevent or minimize a member's physical health regression and deterioration. Tasks performed during the provision of PC services include, but are not limited to, assisting an individual in performing tasks of personal hygiene, dressing and medication. Tasks may also include meal preparation, light housekeeping, errands, and laundry directly related to the recipient's personal care needs. Personal care does not include the provision of care of a technical nature. For example, tracheal suctioning, bladder catheterization, colostomy irrigation and operation/maintenance of technical machinery is not performed as part of PC services. PC skilled nursing service is an assessment of the member's needs to determine the frequency of PC services and tasks performed, development of a PC service care plan to meet identified personal care needs, service delivery oversight and annual re-assessment and updating of care plan. It may also include more frequent re-assessment and updating of the care plan if changes in the member's needs require.
(1) Adults. Payment for services provided by a PC services agency is made on behalf of eligible individuals who have needs requiring the service in accordance with OAC 317:35-15-4 as determined through an assessment utilizing the Uniform Comprehensive Assessment Tool (UCAT). Before PC services can begin the individual must:
(A) require a care plan involving the planning and administration of services delivered under the supervision of professional personnel;
(B) have a physical impairment or combination of physical and mental impairments;
(C) lack the ability to meet personal care needs without additional supervision or assistance, or to communicate needs to others; and
(D) require assistance, not of a technical nature, to prevent or minimize physical health regression and deterioration.
(2) Children. Coverage for persons under 21 years of age is the same as for adults.

317:30-5-952.Prior authorization
[Revised 04-01-09]
 Eligible members receiving personal care services must have an approved care plan developed by a PC services skilled nurse. For persons receiving ADvantage Program services, the nurse works with the member's ADvantage Program Case Manager to develop the care plan. The amount and frequency of the service, to be provided to the member, is listed on the care plan. The amount and frequency of PC services is approved by the OKDHS nurse or authorized in the ADvantage Program Service Plan. At the time of a member's initial referral to a PC services agency, OKDHS/ASD authorizes PC services, skilled nursing for PC services, needs assessment and care plan development. The number of units of PC services or PC skilled nursing the member is eligible to receive is limited to the amounts approved on the care plan as authorized by OKDHS/ASD. Care plans are authorized for no more than one year from the date of care plan authorization. Services provided without prior authorization are not compensable.
317:30-5-953.Billing
[Revised 09-14-18]

A billing unit for personal care services provided by a home care agency is 15 minutes of service delivery and equals a visit. Billing procedures for personal care services are contained in the Oklahoma Medicaid Management Information Systems (OKMMIS) Billing and Procedure Manual.  Service time for personal care and nursing is documented solely through the Electronic Visit Verification (EVV) system. The EVV system provides alternate backup solutions when the automated system is unavailable.  In the event of EVV backup system failure, the provider documents time in accordance with their agency backup plan.  The agency's backup procedures are permitted only when the EVV system is unavailable.

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.