Bill:

Regarding the hours, since all cases are overseen by an RN case manager, clinical supervisor, or clinical director, could the client then receive more than 40 hours of care provided by different PFCs? For example, if the child qualifies for 112 hours of PDN but no nursing is available, then Mom and whoever she chooses to get trained for the case can provide these hours as a PFC each week. She would still be overseen by an RN case manager who works for the agency, but this way, the medically necessary hours can be filled. I would limit the number of hours a PFC can work to 40 hours a week to prevent burnout.

About eligibility, do any of these clients already qualify for another waiver through OHCA or DDSD? In some of my states, they will be eligible for another waiver in addition to the PDN services, which then makes their eligibility dependent on their income rather than that of their parents.

Another possibility that has been brought to my attention in another state is income under section 1902(r)(2), which allows states to disregard certain types of income. This would only require a state plan amendment or could be part of the overall PFC state plan amendment. 

OHCA Response: 

Thank you for your comments and thoughtful suggestions.

Regarding the PFC hours, since they are provided concurrently with PDN hours, any medically necessary care exceeding the 40-hour weekly limit for PFC services should be delivered through RN or LPN-level services. This ensures that members can receive the appropriate level of care while also adhering to the guidelines set forth in the Oklahoma Nursing Practice Act (§567.3a). This approach also helps to prevent overburdening caregivers and ensures compliance with state regulations.

Additionally, flexibility is provided in determining weekly service hours. The 40-hour limit is not a rigid requirement; caregivers may choose to work fewer hours (e.g., 20 hours per week) in collaboration with their provider or employer, as long as the total does not exceed the maximum allowable hours.

Regarding eligibility, while some members may qualify for other waivers through OHCA or DDSD, specific data on this is not available at this time. As the PFC program is newly introduced, a conservative approach is being taken initially. As more experience is gained with the program and additional feedback is received from providers and families, eligibility criteria and services will be adjusted as needed.

Regarding the suggestion on income disregard under section 1902(r)(2), the reference is appreciated and will be considered in future updates to the PFC State Plan Amendment as the program progresses.

Thank you again for the input. Collaboration is valued, and the effectiveness of the program will continue to be assessed.

Bill:

We propose setting the rate for PFC providers at $35.00 per hour. Currently, PDN rates are $40.00, and the highest personal care rate is $26.32.

Since PFC providers will be delivering skilled care similar to what a nurse provides, their reimbursement must align more closely with provider nursing rates rather than those of non-medical personal care assistants. This adjustment would ensure that PFC providers receive a livable wage while enabling agencies to cover the necessary clinical oversight required for this program, which is not present in standard personal care services.

OHCA Response: 

 As we continue the rate-setting process, we will make note of this. Currently, we plan to proceed with the rate of $26.32/hour. We sincerely appreciate your engagement and input to this discussion.

Teri:

1. Delegation of tasks/scope of care allowed. Under the rule, complex caregivers are authorized to provide care under the direction and supervision of an RN or LPN, "in accordance with the Oklahoma Nursing Practice Act, § 567.3a." That Act allows RNs and LPNs to delegate tasks "as defined in" the Board of Nursing rules. Can you share a list of specific tasks that can be delegated to complex caregivers vs. any that cannot be delegated? Can you confirm whether the following are allowed to be delegated: tracheostomy care; IV or other medication administration, including controlled substance; and/or ventilator care?

2. Training requirements. Can you confirm that home care agencies are expected to develop their own 80-hour training programs? And that hospitals will also do training? If yes, can agencies accept hospital training and competency verification if they meet the rule's requirements and an agency opts to do so?  Will OHCA approve or audit individual training programs?

3. Training topics. Can you clarify that in addition to the specific training topics listed in the rule, additional training topics for complex caregivers are expected to be child-specific, depending on an individual child's need?

4.  Portability of training. If a caregiver changes home care agencies, some agencies are likely to require new training and verification of competencies. Are any or all of the training/certifications portable?

5. Reimbursement for training. Will the state reimburse agencies for any or all of the 80 training hours?

6. Patients with 40 total hours. For the patients that only have 40 hours a week. Will a complex caregiver be allowed to work all 40 hours with no hours worked by an LPN or RN? Is there a minimum number of hours that are required to be PDN hours? 

7. Adults (21+). It appears that patients who are part of the Medically Fragile Waiver are excluded from this program since they are over 21 years of age. Is there any plan to expand the program to include patients receiving services under this Waiver? If not, will OHCA help to communicate the program's limits and exclusions to patients and families?

8. SoonerSelect. Will SoonerSelect (MCOs) be required to adopt this program, with the same rules and guidelines? Will MCOs be required to reimburse at least at the $26.32 reimbursement rate?

9.  Additional policies. Is OHCA developing additional written policies with more details on program implementation, including more details on training requirements and other program implementation specifics?

10. Income & Medicaid eligibility. Thank you for clarifying that a family's income from this program could impact Medicaid eligibility. Will OHCA help to create education materials and communicate to patients and families to help them understand the potential impact this income could have on their Medicaid eligibility? 

OHCA Response:

1. According to the Oklahoma Nurse Practice Act, 567.3a, “Registered nursing” means the practice of the full scope of nursing which includes, but is not limited to delegating such tasks as may safely be performed by others, consistent with educational preparation and that do not conflict with the provisions of the Oklahoma Nursing Practice Act 

2. All five Private Duty Nursing agencies in conjunction with OU Children’s Hospital and The Children’s Hospital at Bethany developed base information that is required of all caregivers, and then member specific topics based on the child’s condition. 

3. Training will be a combination of generalized topics and then individualized health topics required to meet the needs of the child. 

4. All training is portable except for the Agency Specific New Employee Orientation  

5. Compensable services would be specifically linked to the T1000 code or the proposed T1004 code.

6. Yes, the complex caregiver will be allowed to work all 40 hours if agreed upon by the agency and caregiver. The RN is still required to assess the member for the periodic updated plan of care and updated provider orders. 

7. OHCA has reviewed this with the Member Advisory Task Force and explained that the Medically Fragile Waiver would require a Waiver Amendment. Currently, staff are engaged in transitions of care activities including changes that occur going from pediatric to adult benefits. 

8. SoonerSelect will be required to adopt this benefit and will have the same fee schedule per 56 O.S. § 4002.12 (OSCN 2025) until July 1, 2027. 

9. No, these are the policies surrounding the Paid Family Caregiver Benefit. 

10. OHCA encourages any caregiver/family member who is endeavoring to pursue this employment to reference OHCA’s public income guidelines for SoonerCare Services