Definitions
As you browse this website, you may see some new words. Here is what we mean when we use them.
Abuse: Provider or member practices that result in an unnecessary cost to the Medicaid program or in reimbursement for services that are not medically necessary.
Advance Directive: A set of directions you give about the medical and behavioral health care you want if you ever lose the ability to make decisions for yourself. This may include a living will, the appointment of a health care proxy or both.
Adverse Benefit Determination: A decision SoonerCare can make to reduce, stop or restrict your health care services.
Aged, Blind and Disabled (ABD): the Medicaid covered populations under 42 United States Code (U.S.C.) Section 1396a (a)(10)(A)(i) and (F).
American Indian/Alaska Native (AI/AN): An individual who is a member of a federally recognized American Indian Tribe; an individual who resides in an urban center and qualifies as a member of an American Indian Tribe, Alaska Native, or is considered an American Indian under federal regulations; an individual considered by the federal government to be an American Indian for any purpose. AI/AN may be used to refer to this population.
Appeal: A request to SoonerCare to review a decision SoonerCare made about reducing, stopping, or restricting your health care services.
Behavioral Health Emergency: A situation in which there is a high risk of behaving in a way that could result in serious harm or death to yourself or others.
Behavioral Health Services: Mental health (emotional, psychological, and social well-being) and substance use (alcohol and drugs) disorder diagnostic, treatment, and rehabilitation services.
Benefits: Medical and behavioral health care services covered by your health plan.
Board: the board designated by the Oklahoma legislature to establish policies and adopt and promulgate rules for the Oklahoma Health Care Authority.
Care Manager: A specially trained health professional who works with you and your doctors to make sure you get the right care when and where you need it.
Copay: A fee you pay when you get certain health care services or a prescription.
Cost Sharing Limit: The monthly limit of total copays a member will pay. For SoonerCare, the cost sharing limit is 5% of the household income.
Custody: the custodial status, as reported by the Oklahoma Department of Human Services.
Durable Medical Equipment: Certain items (such as a walker or a wheelchair) your doctor can order for you to use if you have an illness or an injury.
Emergency Medical Condition: A situation in which your life could be threatened, or you could be hurt permanently if you don’t get care right away (such as a heart attack or broken bones).
Emergency Room Care: Care you receive in a hospital if you are experiencing an emergency medical condition.
Emergency Services: Services you receive to evaluate, treat or stabilize your emergency medical condition.
Emergency Medical Transportation: Ambulance transportation to the nearest hospital or medical facility for an emergency medical condition.
Excluded Benefits: Services or benefits that are not covered by the health plan.
Expansion Adult: An individual who is age 19 or older and under 65, not eligible for Medicare, with income at or below 138% of the federal poverty level, and who is determined eligible for Medicaid.
Expedited (faster) Appeal: A request to SoonerCare to review a decision SoonerCare made about reducing, stopping or restricting your health care services within 72 hours, if you think waiting 30 days for an appeal decision will harm your health.
Fraud: Intentional deception or misrepresentation made by a person resulting in some unauthorized benefit to themselves or another person.
Grievance: A complaint you can file if you have a problem with your SoonerCare provider, care or services.
Habilitation Services and Devices: Health care services that help you keep, learn or improve skills and functioning for daily living.
Health Insurance: A type of insurance coverage that pays for your health and medical costs. Your Medicaid coverage is a type of insurance.
Home Health Care: Certain services you receive outside a hospital or a nursing home to help with daily activities of life, such as home health aide services or skilled nursing.
Hospice Services: Special services for patients and their families during the final stages of illness. Hospice services include certain physical, psychological and social services that support terminally ill individuals and their families or caregivers.
Hospital Outpatient Care: Care you receive at a hospital or medical facility without being admitted or for a stay of less than 24 hours (even if this stay occurs overnight).
Hospitalization: Admission to a hospital for treatment that lasts more than 24 hours.
Indian Health Care Provider (IHCP): A health care program operated by Indian Health Services or by an American Indian Tribe, Tribal Organization, or Urban Indian Organization. IHCP may be used to refer to this kind of provider. Any individual who is an American Indian or Alaska Native (AI/AN) may choose an IHCP as their patient-centered medical home.
Managed Care: An organized way for providers to work together to coordinate and manage all your health needs.
Medicaid: A state health plan that helps some individuals pay for health care. For example, the SoonerCare plan is a Medicaid health program that pays for health coverage for some Oklahomans.
Medically Necessary: Medical services or treatments that you need to get and stay healthy. Services must follow standards and guidelines for the prevention, diagnosis or treatment of symptoms of illness, disease or disability.
Member: A person enrolled in and covered by a health plan.
Network (or Provider Network): A group of doctors, hospitals, pharmacies and other health care professionals who have a contract with your health plan to provide health care services for its members.
Non-Emergency Medical Transportation: Transportation your plan can arrange to help you get to and from your appointments, including personal vehicles, taxis, vans, mini-buses and public transportation.
Non-Expansion Adult: An adult who qualifies for Oklahoma’s Medicaid program and meets eligibility requirements such as pregnant women and parent/caretakers of dependents under age 19 who meet income limits.
Non-Participating Provider/Out-of-Network Provider: A physician, a pharmacy, or any other provider who has not contracted with the SoonerCare program.
Notice of Adverse Resolution: Written information the plan sends you if the plan makes a decision against an appeal you have filed with the plan.
Notice of Resolution: Written information the plan sends you after the plan makes a decision about an appeal you filed with the plan.
Oklahoma Health Care Authority (OHCA): The state agency for Medicaid in Oklahoma, and the agency that oversees the SoonerCare program.
OKDHS: the Oklahoma Department of Human Services.
Out-of-Network Referral: If your health plan does not have the specialist you need in its provider network, they may find one for you to visit who is outside your health plan.
Participating Provider: A physician or other provider, including a pharmacy, who is contracted with the SoonerCare program.
Patient-Centered Medical Home (PCMH): The medical provider who takes care of and coordinates all your health needs, including referrals and prior authorizations. You may have seen this provider called a primary care provider or PCP. Your PCMH is often the first person you should contact if you need care. Your PCMH can be a physician, including an OB/GYN, a nurse practitioner, a physician assistant, or a certified nurse midwife. If you are an individual who is American Indian or Alaska Native (AI/AN), you may choose an Indian Health Care Provider as your PCMH.
Physician Services: The services provided by an individual licensed under state law to practice medicine or osteopathy, but not services offered by doctors while you are admitted in the hospital.
Premium: A monthly payment made for health insurance coverage. You do not have a premium in SoonerCare.
Prior Authorization (or Preauthorization): The approval needed from SoonerCare before you can get certain health care services or medicines.
Prescription Drugs: A drug that, by law, requires a prescription by a doctor.
Prescription Drug Coverage: Health insurance or plan that helps pay for prescription drugs and medications.
Primary Care Case Management: a managed care health service delivery system in which health services are delivered and coordinated by Primary Care Providers.
Primary Care Physician: A medical doctor who is trained to prevent, diagnose, and treat a variety of illnesses and injuries in the general population.
Primary Care Provider (PCP): The medical provider who takes care of and coordinates all your health needs, including referrals and prior authorizations. This provider is also called your Patient-Centered Medical Home (PCMH), and this handbook uses PCMH in place of PCP.
Provider: A health care professional or a facility that delivers health care services, such as a doctor, hospital, or pharmacy.
Rehabilitation Services and Devices: Health care services and equipment that help you regain skills, abilities, or knowledge that may have been lost or compromised because of an illness, accident, injury, or surgery. These services can include physical or speech therapy or behavioral rehabilitation services.
Skilled Nursing Care: Care that requires the skill of a licensed nurse.
SoonerCare: The name of Oklahoma’s Medicaid program.
SoonerCare Choice: a comprehensive medical benefit plan featuring a medical home including a PCP for each member.
SoonerRide: Transportation services for non-emergency medical appointments included in your SoonerCare benefit.
Specialist: A doctor who is trained and practices in a specific area of medicine.
Specialty Care: Advanced medically necessary care that focuses on specific health conditions or are provided by a specialist.
Standard Appeal: A request to SoonerCare to review a decision SoonerCare made about reducing, stopping, or restricting your health care services. SoonerCare will make a decision on your appeal within 30 days.
State Fair Hearing: A process you may request so you can make your case before an administrative law judge if you are not happy about a final decision made that reduced, stopped, or restricted your services after your appeal.
Substance Use: A condition that includes the misuse or addiction to alcohol and/or legal or illegal drugs.
Urgent Care: Care for a health condition that needs prompt medical attention but is not an emergency medical condition. You can get urgent care in a walk-in clinic for a non-life-threatening illness or injury (such as the flu or sprained ankle).
Waste: The overuse or misuse of health care services that increases Medicaid costs.
