Medicaid – Soonercare Traditional

Purpose

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. SoonerCare Traditional program covers a broad range of medical services for categorically qualified persons with low income. In Oklahoma, SoonerCare is administered by the Oklahoma Health Care Authority (OHCA). Assistive technology is purchased as durable medical equipment (DME).

Contact(s)

OK Health Care Authority
4345 N Lincoln Blvd.
Oklahoma City, OK 73105
(405) 522-7300

SoonerCare Helpline
(800) 987-7767
(800) 757-5979 (TDD)
FAX: (405) 530-3426
www.OKHCA.org

Eligibility

Medicaid SoonerCare Traditional program is provided to certain SoonerCare members that are currently exempt from SoonerCare Choice that includes:

  • residents of long-term care facilities;
  • people with private Health Maintenance Organization (HMO) coverage;
  • dually eligible for SoonerCare and Medicare;
  • children in state or tribal custody;
  • 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

How to Get the AT

  • Apply online at http://www.okhca.org, click on “Apply for SoonerCare,” then click on “go to Online Enrollment."
  • 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 and be sure to ask what types of medical, financial and other information to bring to the appointment.  If you are receiving SSI payments or cash assistance (TANF), you must apply at your local DHS office.
  • Enrollment is also available at the State Health Department or an Indian Health Center.
  • Website for Pre Authorizations is now- https://oklahoma.gov/ohca/providers/medical-authorization-unit.html 

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 then give it to a DME supplier.  The DME supplier must be contracted with the SoonerCare program (e.g., on SoonerCare’s approved vendor list).
  • SoonerCare will not pay for the 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 member until no longer needed.
  • When the SoonerCare member no longer needs the valuable DME they may contact the Oklahoma Device Reuse Program 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 Oklahoma Device Reuse Program staff at 833-431-9706 or go to Oklahoma Device Reuse Program for more details.

Dispute Resolution Process

  1. Call the SoonerCare Helpline. The SoonerCare Helpline will make a full report of your problem and work with you to try to resolve it, or;
  2. The appeals process allows a member to appeal a decision involving medical services, prior authorizations for medical services, or discrimination complaints.
  3. 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 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.
  4. 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.
  5. 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 Chief Executive Officer (CEO), which is a record review at which the parties do not appear.
  6. 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.