Medicaid – SoonerCare Choice

Medicaid - SoonerCare Choice

Oklahoma Health Care Authority

Purpose

SoonerCare Choice is a Primary Care Case Management (PCCM) Program in which each member has a medical home. The medical home provider will coordinate all health care services to qualifying Oklahomans. SoonerCare is administered by the Oklahoma Health Care
Authority (OHCA).  OHCA contracts with designated PCCM to be SoonerCare providers. You must go to your PCCM for most of your health care needs. If you need care that your PCCM can’t provide, he/she will refer you to an appropriate specialist. Assistive technology is purchased as Durable Medical Equipment (DME) through a fee for service with contracted vendors.

Contact(s)

Becky Pasternik-Ikard
Deputy State Medicaid Dir.
Oklahoma Health Care Authority
2401 NW 23rd, Ste 1A
Oklahoma City, OK 73107
(405) 522-7300
http://www.okhca.org/individuals.aspx?id=548

SoonerCare Helpline
(800) 987-7767
(800) 757-5979 (TDD)
FAX: (405) 530-3426

Financial Criteria

  • See “Eligibility”

Eligibility

  • Individuals qualifying under the “Temporary Assistance for Needy Families” are eligible
  • must meet income and resource tests for eligibility and be medically needy
  • pregnant women (Soon-To-Be Sooners have limited pregnancy benefits) and/or children under the age of 18 with a family income at/or below 185% of the federal poverty level
  • pregnant women at/or below 133% of federal poverty level receive a full scope of SoonerCare Choice services
  • financial eligibility is determined at the local DHS office
  • may be categorically eligible if individuals are over 65 years old, blind, or disabled
  • all persons receiving Supplementary Security Income (SSI) benefits from the Social Security Administration are eligible to make a separate application to the county DHS office for Medicaid services
  • persons above the income limits may receive assistance by utilizing a “spend down” procedure if they are categorically related

AT Services Provided/Covered

  • Assessments & Evaluations
  • Information & Referral
  • Maintenance & Repair

AT Devices Provided/ Covered

  • Aids for Daily Living
  • Mobility/Seating & Positioning

Application Process

  • Apply online at http://www.okhca.org and click on “Enroll Online Now”
  • Application for SoonerCare can be made at the local Department of Human Service Office. There is at least one office in every county in Oklahoma. Call BEFORE you go to apply. It will be necessary to make an appointment and be sure to ask what types of medical, financial and other information to bring to the appointment.  If you are receiving SSI payments or cash from Temporary Cash Assistance for Needy Families (TANF), you must apply at your local DHS office.
  • Enrollment is also available at the State Health Department or an Indian Health Center.

Dispute Resolution Process

  1. Call the SoonerCare Helpline.  The SoonerCare Helpline will make a full report of your problem and work with you to try to resolve it, or;
  2. The appeals process allows a member to appeal a decision involving medical services, prior authorizations for medical services, or discrimination complaints.
  3.  In order to file an appeal, the member files a LD-1 form within 20 days of the triggering event.  The triggering event occurs at the time when the member knew or should have known of such condition or circumstance for appeal.  The staff advises the Appellant that if there is a need for assistance in reading or completing the grievance form that arrangements will be made.
  4. If the LD-1 form is not received within 20 days of the triggering event or if the form is not completely filled out with all necessary documentation OHCA sends the Appellant a letter stating the appeal will not be heard.
  5. Upon receipt of the member’s appeal, a Fair Hearing before the Administrative Law Judge (ALJ) will be scheduled.  The member will be notified in writing of the date and time for this procedure.  The member must appear at this hearing.  The ALJ’s decision may be appealed to the CEO, which is a record review at which the parties do not appear.
  6. Member appeals are to be decided within 90 days from the date OHCA receives the member’s timely request for a Fair Hearing unless the member waives this requirement.

Pieces of the Puzzle

  • SoonerCare Choice combines a managed care approach to services through the use of a Primary Care Case Management (PCCM) and the state reimbursement on a fee-for-service to other community   providers such as specialist, pharmacists and durable medical equipment vendors.
  • SoonerCare Choice covers many health care services. However, there are limitations that apply to ensure that only medically necessary services are provided. Some services are for children only. Medicaid recipients exempt from SoonerCare Choice remain in the fee-for-service SoonerCare Traditional program.
  • These include individuals who are:
    • dually-eligible for Medicaid and Medicare;
    • in state custody such as foster care;
    • reside in an institution such as a nursing facility; or
    • served through a Home and Community-Based Waiver, such as the ADvantage Waiver Program and In-Home Support Waiver Services.
  • Not all types of AT devices can be purchased under Medicaid. OHCA will either purchase or rent DME that is prescribed by an approved medical provider and is medically necessary.
  • Questions about Medicaid coverage of specific items should be directed to the Oklahoma Health Care Authority, SoonerCare Helpline (800) 987-7767 or 711 TDD.
  • Medicaid does not reimburse the member directly for medical expenses incurred.  Adults have co-pays for most SoonerCare covered services; children do not have co-pays.
  • Medicaid is the payor of last resort on equipment purchases. If an individual has health insurance, Medicaid only begins paying after the health insurance ceases to pay.
  • All DME purchased with Oklahoma Medicaid funds becomes the property of the OHCA to be used by the member until no longer needed
  • When the SoonerCare member no longer needs the valuable DME they may contact the Oklahoma Durable Medical Equipment Reuse Program (OKDMERP) so it can be refurbished, repaired if needed, and reassigned to another Oklahoman at no cost. Priority is given to SoonerCare members for the first 60 days. Call OKDMERP staff at (405) 523-4810 or go to http://okabletech.okstate.edu for more details.