Medicaid – SoonerCare Child Health

Medicaid – SoonerCare Child Health

Purpose

SoonerCare (Oklahoma Medicaid) provides health care services for children covered by SoonerCare from birth through 20 years of age. Children receive a broad range of primary and preventive health services. SoonerCare covers regular and periodic exams to identify health conditions and provide referral and access to medically necessary health care services.  Medically necessary AT devices and services may be covered, even if that service is not covered in Oklahoma’s Medicaid state plan.

Contact(s)

Oklahoma Health Care Authority
4345 N. Lincoln Blvd.
Oklahoma City, OK 73105
(405) 522-7300
http://tinyurl.com/24mnpgq
SoonerCare Helpline:
(800) 987-7767

Eligibility

  • All children ages 0-20 years who are enrolled in SoonerCare;
  • meet financial income and resources standards;
  • a resident of Oklahoma and meet citizenship or legal immigration status; and
  • check specific SoonerCare eligibility information at mysoonercare.org.

AT Services Provided/Covered

  • Assessments & Evaluations
  • Training for Consumer
  • Maintenance & Repairs
  • Case Management

AT Devices Provided/Covered

  • Aids for Daily Living
  • Speech Communication
  • Aids for Hearing Impaired
  • Aids for Vision Impaired
  • Mobility/Seating & Positioning

How to Get the AT

  • Apply online at mysoonercare.org.
  • Enrollment assistance is available by calling the SoonerCare helpline or visit the local Community Action Agency.
  • Prior Authorization for all types of durable medical equipment (DME) is required by the Oklahoma Health Care Authority. It is the responsibility of the chosen DME provider to submit requests for review. DME providers will need to obtain supporting objective documentation (including items like an evaluation report and a Certificate of Medical Necessity (CMN) (as applicable)) from a qualified therapist (Ex. Occupational Therapist, Physical Therapist, or Speech Language Pathologist) required for prior authorization request submissions. Prior authorization guidelines can be found at: http://okhca.org/providers.aspx?id=594&menu=74&parts=7669 on the following types of DME:
    • Audiology Services
    • Communication (Alternative Augmentative Communication) Devices
    • Durable Medical Equipment
    • Incontinence Supplies
    • Wound Care Supplies
    • Vision

Pieces of the Puzzle

  • If approved for SoonerCare, choose a Primary Care Physician (PCP) right away and make an appointment for the child. It is important to visit with the PCP, even if the child is not sick, to build a health history and relationship with the child’s doctor.
  • Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) can offer expanded services to children ages 0-20 years that are not available to other SoonerCare members. These EPSDT services can include AT devices and services that have been and continue to be excluded in the state plan for the regular Medicaid program.
  • Not all types of AT devices will be covered through SoonerCare. There must be a medical need, which must be clearly demonstrated on a case-by-case basis, for an AT device. “Medically necessary” service means medical, dental, behavioral, rehabilitative or other health care services which are:
    • reasonable and necessary to prevent illness or medical conditions, or provide early screening, interventions, and/or treatment for conditions that cause suffering or pain, cause physical deformity or limitation in function, cause illness or infirmity, endanger life, or worsen a disability;
    • provided at appropriate facilities and at the appropriate levels of care for the treatment of a member’s medical conditions;
    • consistent with the diagnosis of the condition;
    • no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, efficiency and independence; and
    • assisting the individual in achieving or maintaining maximum functional capacity in performing daily activities, taking into account both the functional capacity of the individual, and those functional capacities that are appropriate for individuals of the same age.
  • The amount, duration, or scope of services to members may not be denied arbitrarily or reduced solely because of the diagnosis, type of illness, or condition. Appropriate limits may be placed on services based on medical necessity.
  • Incontinence supplies will be provided to children 4-20 who have a documented medical necessity.
  • According to the Oklahoma Health Care Authority (OHCA), AT refers to those medically necessary devices used by an individual with a disability to enhance developmental skills, learning, and adaptation to the individual’s environment. These devices must be unique, customized or personalized to the specific individual. AT devices include, but are not limited to, cognitive and developmental aids, and alternative augmentative communication aids.
  • SoonerCare payment is payment in full. Providers may not bill both the individual and SoonerCare.
  • SoonerCare is the payor of last resort for equipment purchases. If an individual has private health insurance, SoonerCare only begins paying after the health insurance stops.
  • Schools may be SoonerCare providers and receive reimbursement for services that are provided under the Individuals with Disabilities Education Act (IDEA) if the school district contracts with OHCA.
  • Due to parental income, some children with disabilities may not have been eligible for SoonerCare prior to the age of 18, but may become income eligible for SoonerCare and could receive services through age 20.
  • All durable medical equipment (DME) purchased by SoonerCare is 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 833-431-9706 or go to okabletech.org for more details.

Appeals Process

  1. The appeals process allows a member to appeal a decision involving a denial of services or a reduction of services.
  2. In order to file an appeal, the member files a Lobbying Disclosure (LD)-1 form within 20 days of the triggering event.  The triggering event is the time when the member knew or should have known of the circumstance for the appeal. Arrangements will be made if the member needs assistance in reading or completing the grievance form.
  3. If the appeal is one that can be heard before the agency, a Fair Hearing before an Administrative Law Judge (ALJ) will be scheduled. The member will be notified in writing of the date and time for the hearing. After the hearing, the ALJ will issue a decision and the written decision will be sent to the member. The ALJ’s decision may be appealed to the Chief Executive Officer (CEO), which is a record review at which the parties do not appear.