SoonerSelect FAQ for Providers

Oklahoma Health Care Authority (OHCA), in partnership with contracted entities (CEs) or health plans, has implemented a health care delivery model called SoonerSelect. This model consists of health and dental CEs that are responsible for coordinating whole-person care for enrollees.

The following SoonerCare populations are automatically enrolled in SoonerSelect:

• Children, including foster children
• Low-income parents
• Pregnant women
• Non-disabled adults ages 19-64
• Juvenile justice-involved children

The SoonerSelect Children’s Specialty Program covers SoonerSelect children and youth served by Oklahoma Human Services’ Child Welfare Services. This includes children in foster care and former foster care children, those receiving adoption assistance, and those involved in the juvenile justice system. Eligible American Indian/Alaska Native members have the option to enroll in a SoonerSelect plan.

This change went into effect on the following dates:

• February 2024: SoonerSelect dental program
• April 2024: SoonerSelect health and Children’s Specialty Program

SoonerSelect streamlines administrative processes for providers. For example, CEs must:

• Use a single vendor for credentialing and provider portal. Until July 1, 2025, all SoonerSelect health CEs will approve providers actively enrolled with OHCA without requiring full credentialing. CEs will leverage existing credentialing for providers who are already credentialed with a CE either for SoonerSelect or for another existing product line.
• Utilize the standardized OHCA-developed prior authorization request criteria.
• Utilize online prior authorization requests.
• Pay 90% of complete or “clean” claims within 14 days of receipt, and 99% of all clean claims within 90 days of receipt.

All the CEs are required to credential and recredential network providers through a single, consolidated provider enrollment and credentialing process. Additionally, all CEs are required to use the same single credentialing verification organization (CVO) certified by a CMS-approved accrediting organization as part of the provider credentialing and recredentialing process.

To make the transition to SoonerSelect easier on the provider community, from now until July 1, 2025, all SoonerSelect health CEs will approve providers actively enrolled with OHCA without requiring full credentialing. Providers must still be contracted with each CE that is serving the provider’s patients transitioning into SoonerSelect, but providers will not have to go through full credentialing until July 1, 2025.

Each CE continues to pay providers for the services they are rendering. CEs also pay providers who may be outside their network at the same rate as their own providers for the first 90 days after launch. After this period, all contracted providers receive 100% of the reimbursement rate for the applicable service based on OHCA’s fee schedule until July 2027. Providers also have the opportunity to enter into value-based contracts with the CEs.

Each CE has the option to offer extra benefits to help improve the health of its members. Examples of extra benefits include:

• Program for new and expecting mothers with customized support and care.
• Expanded nutritional counseling for members with chronic conditions.
• Home meal delivery during post-hospitalization, acute in-patient stay, and postpartum.

The state invited proposals from all entities, including those that were provider-led, to serve SoonerSelect enrollees. The state reviewed all proposals and selected CEs that best fulfilled all requirements set by the state.

The key difference is the inclusion of provider-led entities (PLEs), which is mandated by state legislation. CEs must either qualify as a PLE or contract with one. To qualify as a PLE, an entity must meet at least one of the following two requirements:

• A majority of the entity's ownership is held by Medicaid providers in Oklahoma, or is held by an entity that directly or indirectly owns or is under common ownership with Medicaid providers in Oklahoma.
• A majority of the entity's governing body is composed of individuals who:
  • Have experience serving Medicaid members and:
    • Are licensed in Oklahoma as physicians, physician assistants, nurse practitioners, certified nurse-midwives or certified registered nurse anesthetists;
    • At least one member is a licensed behavioral health provider; or
    • Are employed by a hospital or other medical facility licensed by and operating in Oklahoma, or an inpatient or outpatient mental health or substance abuse treatment facility or program licensed or certified by and operating in Oklahoma.
  • Represent the providers or facilities described above, including but not limited to individuals who are employed by a statewide provider association; or
  • Are non-clinical administrators of clinical practices serving Medicaid members.

Once contracts were awarded, dental and health CEs began contacting providers in the spring and summer of 2023, respectively. Over the summer, OHCA held meetings to provide an opportunity for providers to meet the SoonerSelect contracted entities. Providers were able to contact the CEs directly to inquire about enrollment and credentialing after the contracts were announced.

Under federal regulation, OHCA is prohibited from requiring a CE to execute any provider agreements beyond the number necessary to meet the needs of enrollees. A CE is also prohibited from excluding any essential community providers, which include the following provider types:

• FQHCs and RHCs
• Family planning providers (Title X family planning clinics and Title X “look-alike” family planning clinics)
• IHCPs
• County health departments or city-county health departments
• Government-funded/operated CMHCs/CCBHCs
• Government-operated state mental health hospitals
• State agencies including but not limited to OJA, OSDH and OHS
• Local, regional and state educational services agencies
• Local health departments
• Long-term care hospitals serving children (LTCHs-C)
• A teaching hospital owned, jointly owned or affiliated with and designated by the University Hospitals Authority, University Hospitals Trust, Oklahoma State University Medical Authority, or Oklahoma State University Medical Trust
• A provider employed by or contracted with, or otherwise a member of the faculty practice plan of a public, accredited medical school in this state or a hospital/health care entity directly or indirectly owned or operated by the University Hospitals Trust or the Oklahoma State University Medical Trust
• A provider employed by or contracted with a primary care residency program accredited by the Accreditation Council for Graduate Medical Education
• A comprehensive community addiction recovery center
• A hospital licensed by the state of Oklahoma, including all hospitals participating the in the Supplemental Hospital Offset Payment Program
• Certified Community Behavioral Health Clinics (CCBHCs)
• Pharmacies without fraud, waste and abuse violations
• Other entities certified by CMS as an essential community as specified under 45 C.F.R. § 156.235

At its discretion, OHCA may add additional providers as essential community providers if the provider either offers services that are not available from any other provider within a reasonable access standard, or provides a substantial share of the total units of a particular service utilized by the enrollees within the region during the last three years, and the combined capacity of other service providers in the region is insufficient to meet the total needs of the enrollees.

CEs provide care management and population health services to coordinate the care of enrollees. CEs offer person-centered and holistic care that identifies and addresses its enrollees' physical health, behavioral health and community and social support needs. To help ensure models of care are developed to meet the needs of Oklahoma’s Medicaid enrollees, each CE must contract with at least one local Oklahoma provider organization.

A local Oklahoma provider organization can be any state provider association, accountable care organization, Certified Community Behavioral Health Clinic (CCBHC), Federally Qualified Health Center (FQHC), Native American tribe or tribal association, hospital or health system, academic medical institution, currently practicing licensed provider, or other local Oklahoma provider organization.

The CE ensures all PAs for covered benefits in place on the day prior to the enrollee’s enrollment with the CE remain in place for 90 days following an enrollee’s enrollment. During this 90-day continuity of care period, PAs may not be denied on the basis that the authorizing provider is not a participating provider. Payment to non-participating providers shall be made at the current Medicaid fee schedule rate and in accordance with OHCA’s payment timeliness standards during the continuity of care period.

The contractor shall allow enrollees with an existing relationship with a non-participating provider to retain that provider during and after the transition to the contractor. The contractor shall continue to pay an enrollee’s existing providers until such time as the contractor can reasonably transfer the enrollee to a participating provider without impeding service delivery necessary to the enrollee’s health or to prevent hospitalization or institutionalization. In the event there is no participating provider available who meets the enrollee’s needs, the contractor shall allow the enrollee to retain their current provider until either the current provider becomes a participating provider or a participating provider who meets the enrollee’s needs becomes available. Notwithstanding the foregoing, enrollees shall be permitted to receive care from a non-participating provider if:

a. The only participating provider available to the enrollee does not, because of moral or religious objections, provide the service the enrollee seeks;

b. The enrollee’s PCP or other provider determines that the enrollee needs related services that would subject the enrollee to unnecessary risk if received separately and not all of these services are available within the network; or

c. OHCA determines that other circumstances warrant out-of-network treatment.

Indian Health Care Providers (IHCPs) will continue to be reimbursed by OHCA for services that are eligible for 100% federal reimbursement. The CEs will make payments to IHCPs for covered services not eligible for 100% federal reimbursement and provided to enrollees who are eligible to receive services through the IHCP, regardless of whether the IHCP is within the CE’s network. The reimbursement equals the applicable encounter rate published annually in the Federal Register by the IHS. In the absence of a published encounter rate, the CE will reimburse the amount the IHCP would receive if the services were provided under the state plan FFS methodology.

In the event the amount the IHCP receives from the CE is less than the amount the IHCP would have received under FFS or the applicable encounter rate published annually in the FR by the IHS, the CE will make a supplemental payment to the IHCP to make up the difference. For more information, please review OHCA’s tribal health care updates.

SoonerSelect requires CEs to proactively address and improve the quality of care in rural parts of Oklahoma. All CEs must not only meet required network adequacy standards set by the state, but they must also implement innovative approaches to improve access to care for Oklahomans living in rural areas.