Library: Policy

317:25-7-2. SoonerCare Choice: overview

Revised 9-14-20

(a) The Oklahoma Health Care Authority (OHCA) operates a Primary Care Case Management (PCCM) system for SoonerCare Choice eligible members.PCCM is a managed care model in which each enrollee has a medical home with a primary care provider (PCP).Enrollees may select their own primary care provider or clinic as their PCP if that provider is enrolled with OHCA as a PCP and as a SoonerCare provider.Those who do not choose a PCP, may be assigned to one (1).Members may change PCPs at any time.

(b) The PCP is paid a monthly care coordination payment in accordance with the conditions in the PCP's SoonerCare Choice contract to provide or otherwise assure the delivery of medically-necessary preventive and primary care medical services, including securing referrals for specialty services and prior authorizations for an enrolled group of eligible members, with the exception of services described in subsection (c) of this Section for which authorization is not required.The PCP assists the member in gaining access to the health care system and monitors the member's condition, health care needs and service delivery.

(c) Services which do not require a referral from a PCP include preventive or primary care services rendered by another SoonerCare contracted provider such as: outpatient behavioral health services; vision services for children; dental services; child abuse/sexual abuse examinations; prenatal and obstetrical services; family planning services; emergency physician and hospital services; chronic disease prevention and management programs and other care coordination programs; and services delivered to Native Americans at Indian Health Service, tribal, or urban Indian clinics.Female members may access a SoonerCare women's health specialist without a referral for covered routine and preventive health care services.This is in addition to the enrollee's PCP if that source is not a woman's health specialist.

(d) SoonerCare Choice covered services delivered by a PCP are reimbursed at the SoonerCare fee schedule rate under the procedure code established for each individual service.If services are provided or authorized by a PCP, the OHCA does not make SoonerCare Choice payments for services delivered outside the scope of coverage of the SoonerCare Choice program; thus, a referral by a PCP does not guarantee payment.

(e) A PCP may charge a co-payment for services provided to SoonerCare members in accordance with Oklahoma Administrative Code (OAC) 317:30-3-5(d).

(f) Members with chronic conditions may elect to enroll in a health management program to improve their health.

(g) PCPs may elect to participate in Health Access Networks pursuant to Subchapter 9 to improve access to care.

(h) PCPs may elect to participate in a Health Management Program pursuant to Subchapter 11 to improve access to care.