What is Medicaid? PDF Version

Medicaid is a health coverage program jointly funded by the federal and state government. This program helps pay some or all medical bills for many people who can't afford them. The Oklahoma Health Care Authority (OHCA) is the state agency that administers the program. The Oklahoma Department of Human Services (OKDHS) determines financial eligibility for the program.

Who is eligible?

To be eligible for Oklahoma Medicaid, a person must:

* reside in Oklahoma;

* be a U.S. citizen or qualified alien;

* meet financial income and resources standards in certain categories.

How to apply?

You may request a medical application for yourself or any other person by mail, telephone or by scheduling an appointment with your Oklahoma Department of Human Services (OKDHS) county office. The OKDHS workers will assist you in gathering the needed information and applying for Medicaid benefits.

      Children and pregnant women

Use a simple form to apply for SoonerCare health insurance for yourself and everyone in your immediate family who lives with you. You may download the application from the OKDHS website: www.okdhs.org/ fill it out and mail it to the address listed on the form. You may also download and fill out the Spanish version of the SoonerCare application.

Individuals 65 or older, individuals with a disability, individuals needing long-term care

You may apply at your local county OKDHS office or download the PS-1 -Request for Services application from the OKDHS website: www.okdhs.org/  The OKDHS workers will assist you in gathering the needed information such as your income, assets, family size and, if available, recent medical information.

What services are paid?

Oklahoma Medicaid 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.

Covered services

* Ambulance

* Ambulatory Surgery Center services

* Behavioral health and substance abuse services (outpatient)

* Case management services

* Chemotherapy and radiation therapy

* Clinic services including renal dialysis services

* Dental services (limited for adults)

* Dentures for adults residing in nursing facilities

* Durable medical equipment and supplies

* Family planning services and supplies

* Federally Qualified Health Center (FQHC) services

* Home health services

* Inpatient hospital services

* Inpatient hospital services in an institution for mental disease for people who are 65 years of age or older *

* Intermediate Care Facilities for the mentally retarded (ICF-MR) *

* Laboratory and X-ray services

* Medical supplies and equipment, including diabetic supplies

* Nurse midwife services

* Nursing facility services (Not covered under SoonerCare)

* Outpatient hospital services

* Personal care services

* Physician services, including preventive services

* Podiatry services

* Prescription drugs and insulin

* Prenatal, delivery and postpartum services (maternity services)

* Rural health clinic services

* Smoking Cessation

* Transplants that are prior authorized

* Transportation to obtain covered medical care (SoonerRide)

* Tuberculosis services.

 

Additional services for children

* Child Health screenings

* Hearing aids

* Immunizations

* Inpatient hospital services for patients in institutions for mental disease

* Optometric or optical services, including eyeglasses

* Orthodontics

* Other medically necessary services

* Physical and occupational therapy

* Private duty nursing

* Speech, hearing and language disorder services

What does it cost?

There is no cost for those who meet the income guidelines; however, co-pays may apply to some services.

Medicaid Provides Durable Medical Equipment & Supplies

Oklahoma Health Care Authority under the Medicaid program provides coverage for durable medical equipment (DME) that is prescribed by the appropriate medical provider, is medically necessary and meets the following definition:

* Can withstand repeated use

* Is used to serve a medical purpose

* Is not useful to a person in the absence of illness or injury, and

* Is used in the most appropriate setting including the home or workplace

The rental of DME is the preferred method of provision if anticipated length of need is less than 10 months.  Certain DME requires a Certificate of Medical Necessity and/or prior authorization such as:

* Rental of hospital beds, support surfaces, wheelchairs, continuous positive airway pressure devices and lifts

* DME with a fee schedule price of $500 or more

* Bath and toilet aids including commode chairs, sitz baths and handrails all have additional restrictions within the provision of prior authorization

Medical Supplies are defined as those disposable items which are used for the care and treatment of a medical condition.  Certain supplies may be excluded from coverage for adults such as:

* Diapers

* Underpads

* Medicine cups

* Eating utensils, and

* Personal comfort items

Diabetic supplies are provided to children and adults but have the following limits for adults:

* One glucometer, one spring loaded lancet device & three replacement batteries per year

* 100 glucose test strips & 100 lancets per month

* Diabetic supplies in excess of these parameters must have prior authorization

 

Early & Periodic Screening, Diagnosis, and Treatment

The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) service is Medicaid's comprehensive and preventive child health program for individuals under the age of 21. EPSDT includes periodic screening, vision, dental, and hearing services. In addition, federal law requires that any medically necessary health care service listed at Section 1905(a) of the Social Security Act is to be provided to an EPSDT recipient even if the service is not available under the State's Medicaid plan to the rest of the Medicaid population.

Screening services must include all of the following services:

* Comprehensive health and developmental history -- (including assessment of both physical and mental health development);

* Comprehensive unclothed physical exam;

* Appropriate immunizations;

* Laboratory tests;

* Lead Toxicity Screening.

Periodicity Schedules -- Periodic Screening, Vision, and Hearing services must be provided at intervals that meet reasonable standards of medical practice. Dental services must be provided at intervals determined to meet reasonable standards of dental practice.

Diagnosis -- When a screening examination indicates the need for further evaluation of an individual's health, provide diagnostic services. The referral should be made without delay and follow-up to make sure that the recipient receives a complete diagnostic evaluation. If the recipient is receiving care from a continuing care provider, diagnosis may be part of the screening and examination process. States should develop quality assurance procedures to assure comprehensive care for the individual.

Treatment -- Health care must be made available for treatment or other measures to correct or ameliorate defects and physical and mental illnesses or conditions discovered by the screening services.

EPSDT defines medically necessary as:

* Prevent illness

* Provide intervention

* At appropriate levels of care

* Proper balance of

o safety,

o effectiveness,

o efficiency, and

o independence

* Achieve or maintain maximum functional capacity

How to Appeal a Medicaid Decision

1. The Oklahoma Health Care Authority (OHCA) appeal’s 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 Medicaid member must file 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 OHCA staff advises the member 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 by OHCA within 20 days of the triggering event or if the form is not completely filled out with all necessary documentation OHCA sends the Appellant member 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. 

What information do you need to put on the LD-1 Form?

The LD-1 Form - asks the normal contact information such as name, address and phone number.  Be sure to include your Medicaid number on the “Case No.” line.  You must include the date of “Adverse Action”.

Answer the following questions:

* I would like to make a complaint about the following individual or organization:

* Please tell us about your complaint in the space below.  Be as specific as possible and whenever possible, give the date(s) that the event occurred.

* Have you told the individual or organization that you have a problem or complaint?  If so, what happened?

* What would you like the Oklahoma Health Care Authority to do about this problem?

Don’t forget to sign and date the form -- attach copies of any supporting documentation you would like to be considered and send it to:

Oklahoma Health Care Authority

Grievance Docket Clerk

Legal Division

P.O. Drawer 18497

Oklahoma City, Oklahoma 73154-0497

OHCA Fax Number is (405) 530-3455

OHCA Docket Clerk Telephone Number is (405) 522-7217

For more information contact Oklahoma Health Care Authority - Customer Service 1-800-522-0114

This document provided by Oklahoma ABLE Tech in partnership with the OCCY Family Perspective Committee

                          

 

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