Library: Policy

317:30-5-557. Coverage by category

Revised 9-12-22

(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 does cover children [under twenty-one (21) years of age] if:

(1) The member is eligible for SoonerCare; and

(2) The Oklahoma Health Care Authority (OHCA), 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 the 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.