Library: Policy

317:25-7-28. Disenrolling a member from SoonerCare Choice

Revised 9-14-20

(a) The Oklahoma Health Care Authority (OHCA) may disenroll a member from SoonerCare Choice if:

(1) The member is no longer eligible for SoonerCare Choice services;

(2) The member is incarcerated;

(3) The member dies;

(4) Disenrollment is determined to be necessary by the OHCA;

(5) The status of the member changes, rendering him/her ineligible for SoonerCare;

(6) The member is authorized to receive services in a nursing facility, in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) or through a Home and Community Based Waiver;

(7) The member becomes dually-eligible for SoonerCare and Medicare; or

(8) The member becomes covered under other creditable coverage.

(b) The OHCA may disenroll the member at any time if the member is disenrolled for good cause, as it is defined in Oklahoma Administrative Code (OAC) 317:25-7-27. The OHCA will inform the PCP of any disenrollments from his or her member roster.

(c) OHCA may disenroll a member upon the PCP's request as described in (1) through (5) of this subsection.

(1) A primary care provider (PCP) may file a written request asking OHCA to take action, including, but not limited to, disenrolling a member when the member:

(A) Is physically or verbally abusive to office staff, providers, and/or other patients;

(B) Is habitually non-compliant with the documented medical directions of a PCP; or

(C) Regularly fails to arrive for scheduled appointments without cancelling and the PCP has made all reasonable efforts to accommodate the member.

(2) The request from a PCP for disenrollment of a member must include one (1) or more of the following:

(A) Documentation of the difficulty encountered with the member, including the nature, extent, and frequency of abusive or harmful behavior, violence, and/or inability to treat or engage the member;

(B) Identification and documentation of unique religious or cultural issues that may be affecting a PCP's ability to provide treatment effectively to the member; or

(C) Documentation of special assistance or intervention offered.

(3) A PCP may not request disenrollment because of a change in the member's health status, the member's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the member's special needs except when the member's enrollment with a PCP seriously impairs his/her ability to furnish services to this member or other members.

(4) A PCP must document efforts taken to inform the member orally or in writing of any actions that have interfered with the effective provision of covered services, as well as efforts to explain what actions or language of the member are acceptable and unacceptable and the consequences of unacceptable behavior, including disenrollment from a PCP.

(5) The OHCA will give written notice of the disenrollment request to the member.