MEDICAID - FEE FOR SERVICE

Oklahoma Health Care Authority (OHCA)

PURPOSE

Medicaid is a joint federal/state medical assistance program that provides coverage of medical expenses for categorically qualified persons with low income. Medicaid covers a broad range of medical services. 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, Medicaid is administered by the OHCA. Assistive technology is purchased as Durable Medical Equipment (DME) under this program. AT devices and equipment may be available as a component of other Medicaid programs such as EPSDT (for children under the age of 21), SoonerCare, and special waiver programs included in this section of the guide. Medicaid- Fee for Service makes payment for covered services provided by health care providers in Oklahoma who have entered into a participation agreement with the program.

CONTACT

Ms. Melody Fish, Medical Authorization Unit

OK Health Care Authority

4545 N Lincoln Blvd., Ste 124

Oklahoma City, OK 73105

(405) 522-7300

OHCA Customer Service

(405) 522-6205

(800) 522-0114

FAX: (405) 530-3426

http://okhca.org/individuals.aspx?id=528&menu=42&parts=7649_7647

See Appendix B for Department of Human Services County Offices.

FINANCIAL CRITERIA

• See “ELIGIBILITY”

ELIGIBILITY

• Medicaid serves persons of ALL ages and ALL types of disabilities. Medicaid-Fee for Service is provided to certain Medicaid recipients that are currently exempt from SoonerCare.

• Medicaid recipients that are to remain in the Fee for Service program include individuals:

• dually eligible for Medicaid and Medicare;

• in-state custody such as foster care; or

• service through a Home and Community-Based Waiver, such as ADvantage Waiver Program and In-Home Support.

• 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 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 otherwise disabled.

• All persons who are receiving Supplementary Security Income (SSI) benefits from the Social Security Administration (SSA) 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

• Maintenance & Repairs

AT DEVICES PROVIDED/COVERED

Aids for Daily Living
Seating/Positioning Equipment

Hospital Beds
Wheelchairs & Mobility Aids

Medical Supplies

APPLICATION PROCESS

• Application for Medicaid is made at your local office of the Department of Human Service. 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 is determined eligible for benefits, contracted medical care providers may seek reimbursement from Medicaid on behalf of the eligible recipient.

APPEALS PROCESS

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

• This complex, constantly changing program allows states to determine specific eligbility guidelines, benefits, and reimbursement policies that are based on broad guidelines from the federal government. Based on Oklahoma Public Law, some Medicaid recipients have been converted to SoonerCare and are no longer in the Fee for Service program.

• 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 any DME that costs more than $500. Additionally, prior authorization is required for rental of hospital beds, support services, wheelchairs, continuous positive airway pressure devices, and lifts. Authorization must again be renewed after five (5) months of rental use.

• Individuals obtain DME by a prescription from a physician to a DME supplier, who is contracted with the Medicaid program (e.g., on Medicaid’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.

• 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 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 becomes the property of the OHCA to be used by the recipient until no longer needed.