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Library: Policy

317:25-7-25. Member enrollment process

Revised 9-14-20

(a) SoonerCare eligible individuals whose eligibility is based on one (1) of the aid categories defined in Oklahoma Administrative Code (OAC) 317:25-7-12 are eligible to enroll with a primary care physician (PCP).Parents or guardians will choose on behalf of minor members in the household.Families with more than one (1) enrollee may choose a different PCP for each family member.

(b) Until the effective date of enrollment with a PCP, services for a newborn are reimbursed at a fee-for-service rate. Upon eligibility determination, newborns may enroll with a PCP who is in general practice, family practice, or general pediatrics.Enrollment materials will advise the parent or guardian of the right to change PCP after the effective date of enrollment.

(c) A description of the PCCM program and the PCP directory are available on the Oklahoma Health Care Authority's (OHCA) website.

(d) For purposes of determining the member's choice of PCP, the most recent PCP selection received by the OHCA determines the PCP with which the member is enrolled, as long as capacity is available.If capacity is not available or the member does not choose, the member is assigned according to the assignment mechanism as defined by the OHCA.A member who is eligible for SoonerCare Choice but is not assigned, may request enrollment with a PCP by contacting the SoonerCare Helpline or through the member's account, if applicable.

(e) PCPs may not refuse an assignment, seek to disenroll a member, or otherwise discriminate against a member on the basis of age, sex, race, physical or mental disability, national origin, or type of illness or condition, unless that condition can be better treated by another provider type, except that Indian Health Service, tribal or urban Indian programs may provide services to members consistent with federal law.

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