Medicaid - SoonerCare Traditional
Oklahoma Health Care Authority
SoonerCare Traditional program covers a broad range of medical services for categorically qualified persons with low income. Some services are mandated by federal law and must be provided by every state, while other services are provided at a state’s discretion. In Oklahoma, SoonerCare is administered by the Oklahoma Health Care Authority (OHCA). Assistive technology is purchased as Durable Medical Equipment (DME). SoonerCare Traditional fee-for-service has a statewide network of providers that includes hospitals, family practice doctors, pharmacies and durable medical equipment companies. SoonerCare members in this program may choose any of these contracted providers for needed services.
Deputy State Medicaid Dir.
OK Health Care Authority
2401 N.W. 23rd, Suite 1A
Oklahoma City, OK 73107
(800) 757-5979 (TDD)
FAX: (405) 530-3426
See Appendix B for Department of Human Services County Offices.
- Medicaid SoonerCare Traditional program is provided to certain SoonerCare members that are currently exempt from SoonerCare Choice; that include:
- residents of long-term care facilities;
- dually eligible for SoonerCare and Medicare;
- children in state or tribal custody; or
- members receiving service through a Home and Community-Based Services (HCBS) Waiver;
- must meet income and resource tests for eligibility and be medically needy;
- must fit into specific categories and must have income and resources below specific thresholds;
- may be categorically eligible if they are over 65 years old, blind or have a disability; and
- all persons who are receiving Supplementary Security Income (SSI) benefits from the Social Security Administration (SSA) are eligible to make a separate application for SoonerCare services.
AT SERVICES PROVIDED/COVERED
- Assessments & Evaluations
- Maintenance & Repairs
AT DEVICES PROVIDED/COVERED
- Aids for Daily Living
- Mobility/Seating & Positioning
- 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 be sure to ask what types of medical, financial and other information to bring to the appointment.
- Apply online at: http://www.okhca.org/individuals.aspx?id=11698
- Enrollment assistance is available by calling the SoonerCare helpline or visit the local Community Action Agency.
- The appeals process allows a member to appeal a decision involving medical services, prior authorizations for medical services, or discrimination complaints.
- 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.
- 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.
- 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.
- 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
- 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”
- OHCA requires prior authorization for most DME.
- Individuals obtain DME by a prescription from a physician given to a DME supplier. The DME supplier must be contracted with the SoonerCare program (e.g., on SoonerCare’s approved vendor list).
- Questions about Medicaid coverage of specific items should be directed to the Oklahoma Health Care Authority (OHCA) Customer Service (800) 522-0114.
- SoonerCare will not pay for services of a non-SoonerCare provider. A provider’s participation in the SoonerCare program is voluntary and SoonerCare members should ask if SoonerCare is accepted before scheduling an appointment or requesting DME.
- Medicaid is the payor of last resort on equipment purchases. If the individual is eligible for Medicare, then Medicaid will only pay the remainder of the cost after Medicare has paid within the limits of the fee schedules. If an individual has health insurance, Medicaid only begins paying after the health insurance ceases to pay.
- All DME purchased with Oklahoma Medicaid funds become the property of the OHCA to be used by the recipient 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 www.okabletech.okstate.edu for more details.