The ADvantage Administration (AA) certifies qualified Personal Care service agencies and facilitates the execution of the agencies' SoonerCare contracts on behalf of OHCA.  OHCA will check the list of providers that have been barred from Medicare/SoonerCare participation to ensure that the Personal Care services agency is not listed.

• (1) Payment for Personal Care.  Payment for Personal Care services is generally made for care in the member's "own home".  In addition to an owned or rented home, a rented apartment, room or shelter shared with others is considered to be the member's "own home".  A facility that meets the definition of a nursing facility, room and board, licensed residential care facility, licensed assisted living facility, group home, rest home or a specialized home as set forth in O.S. Title 63, Section 1-819 et seq., Section 1-890.1 et seq., and Section 1-1902 et seq., and/or in any other type of settings prohibited under applicable federal or state statutes, rules, regulations, or other written instruments that have the effect of law is not a setting that qualifies as the member's "own home" for delivery of Personal Care services through SoonerCare.  With prior approval of the OKDHS area nurse, Personal Care services may be provided in an educational or employment setting to assist the member in achieving vocational goals identified on the care plan.
• (A) Use of Personal Care service agency.  To provide Personal Care services, an agency must be licensed by the Oklahoma State Department of Health, meet certification standards identified by OKDHS and possess a current SoonerCare contract.
• (B) Reimbursement.  Personal Care services payment on behalf of a member is made according to the type of service and number of units of Personal Care services authorized in the Service Authorization Model (SAM) packet.
• (i) The amount paid to Personal Care services providers for each unit of service is according to the established SoonerCare rates for the Personal Care services.  Only authorized units contained in each eligible member's individual Service Authorization Model (SAM) packet are eligible for reimbursement.  Providers serving more than one Personal Care service member residing in the same residence will assure that the members' Service Authorization Model (SAM) packets combine units in the most efficient manner possible to meet the needs of all eligible persons in the residence.
• (ii) Payment for Personal Care services is for tasks performed in accordance with OAC 317:30-5-951 only when listed on an authorized plan of care.  Payment for Personal Care skilled nursing service is made on behalf of the member for assessment/evaluation and associated service planning per assessment/service planning visit by the Personal Care Assessment/Service Planning Nurse.
• (2) Issue resolution.
• (A) If the member is dissatisfied with the Personal Care services provider agency or the assigned PCA, and has exhausted attempts to work with the Personal Care services agency's grievance process without resolution, the member may contact the OKDHS nurse to attempt to resolve the issues.  The member has the right to appeal to the OHCA in accordance with OAC 317:2-1-2.  For members receiving ADvantage services, the member or family should contact their case manager for the problem resolution.  If the problem remains unresolved, the member or family should contact the Consumer Inquiry System (CIS).  Providers are required to provide the CIS contact number to every member.  The ADvantage Program member also has the right to appeal to the OHCA in accordance with OAC 317:2.
• (B) When a problem with performance of the Personal Care attendant is identified, agency staff will conduct a counseling conference with the member and/or the attendant as appropriate.  Agency staff will counsel the attendant regarding problems with his/her performance.
• (3) Persons ineligible to serve as Personal Care Assistants.  Payment from SoonerCare funds for Personal Care services may not be made to an individual who is a legally responsible family member (spouse, legal guardian or parent of a minor child) of the member to whom he/she is providing personal care services.