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OHCA Policies and Rules

OHCA Policies and Rules Main Page

317:30-5-557. Coverage by category

[Revised 03-01-26]

(a) Adults. SoonerCare does not cover adults [twenty-one (21) years of age and over] for private duty nursing (PDN) with the exception of subsection (c).

(b) Children. SoonerCare or SoonerSelect does cover children [under twenty-one (21) years of age] if:

(1) The member is eligible for SoonerCare or SoonerSelect; and

(2) The Oklahoma Health Care Authority (OHCA), or OHCA’s Contracted Entity, in its discretion, deems the services medically necessary. Medical necessity is determined in accordance with Oklahoma Administrative Code (OAC) 317:30-5-560.1.

(c) Individuals eligible for Part B of Medicare. Payment is made utilizing SoonerCare allowable for comparable services.

(d) 1915(c) home and community-based services (HCBS) waivers. If private duty nursing services are provided, they will be defined within each waiver and must be prior authorized.

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.