Oklahoma Health Care Authority (OHCA)
Oklahoma operates a mandatory managed care program, known as SoonerCare, for a portion of its Medicaid population. Medicaid is administered by the Oklahoma Health Care Authority (OHCA). SoonerCare Choice is a Primary Care Provider/Case Manager (PCP/ CM) health care model. OHCA contracts with designated PCP/CM to be SoonerCare Choice providers. You must go to your PCP/CM for most of your health care needs. If you need care that your PCP/CM can’t provide, he/she will refer you to an appropriate specialist. Assistive technology is purchased as Durable Medical Equipment (DME) through fee for service under this program.
Ms. Becky Pasternik-Ikard
Oklahoma Health Care Authority
4545 N Lincoln Blvd, Ste 124
Oklahoma City, OK 73105
OHCA Customer Service
FAX: (405) 530-3426
See Appendix B for Department of Human Services County Offices.
The population covered includes individuals qualifying under the “Temporary Assistance for Needy Families.” Certain Medicaid recipients continue to be exempt from SoonerCare Choice. See “Pieces of the Puzzle.”
Persons qualifying for Medicaid must meet income and resource tests for eligibility and be medically needy. Individuals must fit into specific categories and must have income and resources below specific thresholds. Pregnant women and/or children under the age of 18 with a family income at or below 185% of the federal poverty level must meet financial eligibility criteria. The financial criteria changes frequently; therefore, check at the local DHS office for eligibility.
Persons may be categorically eligible if they are over 65 years old, blind, or disabled.
All persons who are 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 “spenddown” procedure if they are categorically related.
AT SERVICES PROVIDED/COVERED
Assessments & Evaluations
Information & Referral
Maintenance & Repair
AT DEVICES PROVIDED/COVERED
Aids for Daily Living
Wheelchairs & Mobility Aids
Seating & Positioning Equipment
Application for Medicaid is made at your local office of the Department of Human Services. There is at least one office in every county in Oklahoma. Call BEFORE you go to apply. You will have to make an appointment and should ask what types of medical, financial and other information to bring with you to the appointment.
Complete an application form, interview and provide specific information requested. Once an individual has been determined to be eligible for benefits, contracted medical care providers may seek reimbursement from Medicaid on behalf of the eligible recipient.
1. The appeals process allows a member to appeal a decision involving medical services, prior authorizations for medical services, or discrimination complaints.
2. 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.
3. 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.
4. 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.
5. 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 gatekeeper approach to services through the use of a PCP/CM and the state reimbursement on a fee-for-service to other community providers such as hospitals or pharmacists.
Medicaid recipients exempt from SoonerCare Choice remain in the fee-for-service program. These include individuals who are:
dually-eligible for Medicaid and Medicare,
in state custody such as foster care, or
served through a Home and Community-Based Waiver, such as 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, Customer Services (800) 522-0114.
Medicaid does not reimburse the recipient directly for medical expenses incurred. Medicaid payment is payment in full. Providers may not bill both the individual and Medicaid.
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 recipient until no longer needed.