Library: Policy

317:35-15-13.2. Individual personal care assistants (IPCA) provider contractor; billing, training, and problem resolution

Revised 9-12-22

While the Oklahoma Health Care Authority (OHCA) is the contractor authorized under federal law, the Oklahoma Human Services (OKDHS) Health Care Management Nurse (HCMN) I or II initiates initial contracts with eligible members to provide SPPC services per Oklahoma Administrative Code (OAC) 317:35-15-2. OHCA is responsible for IPCA contract renewal.

(1) IPCA payment. Payment for SPPC services is made for care provided in the member's own home or in other limited types of living arrangements per OAC 317:35-15-2(b)(1) through (4). SPPC services may not be approved when the member lives in the Personal Care Assistant's (PCA) home, except with the approval of OKDHS Community Living, Aging and Protective Services.

(A) Reimbursement. Personal care payment for a member is made according to the number of personal care units identified in the service plan.

(i) The amount per unit paid to individual contractors is determined according to the established rates. A service plan is developed for each member in the home and service units are assigned to meet each member's needs. The service plans combine units efficiently to meet all eligible members needs in the household.

(ii) From the total amounts the IPCA bills in (i) of this subparagraph, OHCA, acting as agent for the member-employer, withholds the appropriate FICA tax percentage and sends it to the Internal Revenue Service as the individual contractor's contribution toward Social Security coverage. To ensure the Social Security account is credited, the individual contractor's Social Security number is entered correctly on each claim.

(iii) The contractor payment fee covers all SPPC services included on the service and care plans the OKDHS HCMN I or II develops. Payment is only made for eligible members' direct services and care. The OKDHS HCMN III, authorizes the number of service units the member receives.

(iv) A member may select more than one (1) IPCA. The service and care plan indicates when this is necessary.

(v) The IPCA may provide SoonerCare SPPC services for several households during one (1) week as long as the daily number of paid service units does not exceed eight (8) hours, thirty-two (32) units per day. Total weekly hours cannot exceed forty (40), one-hundred and sixty (160) units.

(B) IPCA wage or employment information release. Any inquiry received by the local office requesting wage or employment information is forwarded to OHCA, Claims Resolution.

(2) IPCA member selection. Members or family members recruit, interview, conduct reference checks, and select applicants for IPCA consideration. Prior to placing an IPCA in the member's home, an Oklahoma State Bureau of Investigation (OSBI) background check and an OKDHS Community Services Worker Registry check are completed per Section 1-1944 through 1-1948 of Title 63 of the Oklahoma Statutes (O.S. 63 '' 1-1944 through 1-948). The OKDHS HCMN I or II also checks the Certified Nurse Aide Registry. The OKDHS HCMN I or II affirms the applicant's name is not contained on any of the registries. The OKDHS HCMN I or II notifies OHCA when the applicant is on any registry.

(A) Persons eligible to serve as IPCAs. SPPC services payment is made IPCAs who meet the criteria per OAC 317:35-15-2(c)(1) through (8).

(B) Persons ineligible to serve as IPCAs. SPPC services payment from SoonerCare funds may not be made to an individual who is the member's legally responsible family member, such as a spouse, legal guardian, or parent of a minor child of the member being served.

(i) Payment cannot be made to or an OKDHS or OHCA employee. Payment cannot be made to an immediate family member of a an OKDHS employee who works in the same county without OKDHS Medicaid Services Unit approval. When a family member relationship exists between an OKDHS HCMN I or II and an IPCA in the same county, the OKDHS HCMN I or II cannot manage services for a member whose IPCA is his or her family member.

(ii) If it is determined that an OKDHS HCMN I or II or an OHCA employee is interfering in service provision for personal or family benefit, the employee is subject to disciplinary action.

(3) IPCA orientation. When a member selects an IPCA, the OKDHS HCMN I or II notifies the selected IPCA to complete the Oklahoma State Department of Health (OSDH) Form 805, Uniform Employment Application for Nurse Aide Staff, and the OKDHS Form 06PE039E, Employment Application Supplement, and for a qualification determination and orientation determination. For SPPC members, this process is the OKDHS HCMN I or II responsibility. The IPCA can begin work after:

(A) The member interviews him or her;

(B) The OKDHS nurse orients him or her;

(D) The effective service date is established;

(E) All registries are checked and the IPCA's name is not listed;

(F) OSDH Nurse Aide Registry is checked and no notations are found; and

(G) OSBI background check is completed.

(4) IPCA training. It is the OKDHS HCMN I or II responsibility to make sure the IPCA has the training needed to carry out the care plan prior to each member's service initiation.

(5) Problem resolution related to IPCA performance. When it comes to the OKDHS HCMN I or II attention there is a problem related to IPCA performance, a counseling conference is held between the member, OKDHS HCMN I or II, and IPCA. The OKDHS HCMN I or II counsels the IPCA regarding problems with his or her performance when doing so results in improved performance.

(6) IPCA Provider Agreement termination.

(A) An IPCA contract termination recommendation is submitted to OHCA and IPCA services are suspended immediately when the IPCA:

(i) Performance poses a threat to the member's health and safety or to others; or

(ii) Failed to comply with PCA Provider Agreement expectations and counseling is not appropriate or effective; or

(iii) Name appears on the OKDHS Community Services Worker Registry or any registry listed in O.S. 63 ' 1-1947, even when his or her name is not on the registry at the time of application or hiring.

(B) The OKDHS HCMN makes the IPCA termination recommendation to OKDHS Community Living, Aging and Protective Services Medicaid Services Unit (MSU), MSU then notifies the OHCA Legal Division of the recommendation. When the problem is related to abuse, neglect, or exploitation allegations OKDHS Adult Protective Services, State Attorney General's Medicaid Unit, OHCA, and OSDH are notified.

(C) When the problem is related to abuse, neglect, or exploitation allegations, the OKDHS HCMN follows the process, per OAC 340:100-3-39.