Library: Policy

317:55-3-10. Covered services

Revised 7-1-23

(a) Amount, duration, and scope of services. The CE or DBM must ensure members have timely access to all medically necessary services, as applicable, covered by SoonerCare under the Medicaid State Plan, the Alternative Benefit Plan (ABP), and the 1115 IMD Waiver. The CE or DBM must ensure:

(1) Services are sufficient in amount, duration, and scope to reasonably be expected to achieve the purpose for which the services are provided;

(2) The amount, duration, and scope of a required service is not arbitrarily denied or reduced solely because of the diagnosis, type of illness, or condition;

(3) PA is available for services on which the CE or DBM has placed a pre-identified limitation to ensure the limitation may be exceeded when medically necessary.

(A) The CE or DBM may propose to impose alternative PA requirements, subject to OHCA's review and approval, except for those benefits identified as exempt from PA. The CE or DBM may be less restrictive on the requirements of a PA than OHCA but may not impose greater restrictions.

(B) PA shall be processed in accordance with timeliness requirements specified in the Contract.

(4) Coverage decisions are based on the coverage and medical necessity criteria published in Title 317 of the Oklahoma Administrative Code and practice guidelines/manual; and

(5) If a member is unable to obtain medically necessary services offered by SoonerCare from a CE or DBM network provider, the CE or DBM must adequately and timely cover the services out of network, until the CE or DBM is able to provide the services from a network provider.

(b) Emergency services. The CE or DBM shall provide emergency services to Enrollees in accordance with the respective CE or DBM Contract.

(c) Post-stabilization services. In accordance with the provisions set forth at 42 C.F.R. § 422.113(c), the CE shall provide post-stabilization care services are:

(1) Obtained within or outside the CE network that are:

(A) Pre-approved by a CE or representative; or

(B) Not pre-approved by a CE or representative but administered to maintain the Enrollee's stabilized condition within one (1) hour of a request to the CE for pre-approval of further post-stabilization care services.

(2) Administered to maintain, improve, or resolve the Enrollee's stabilized condition without preauthorization, and regardless of whether the Enrollee obtains the services within the CE network when the CE:

(A) Did not respond to a request for pre-approval within one (1) hour;

(B) Could not be contacted; or

(C) Representative and the treating physician could not reach agreement concerning the Enrollee's care and a CE physician was not available for consultation.

(3) In accordance with 42 C.F.R. §§ 438.114(e) and 422.113(c)(2)(iv), the CE shall limit charges to Enrollees for post-stabilization care services to an amount no greater than what the CE would charge the Enrollee if they obtained the services through the CE. Additionally, the CE's financial responsibility for post-stabilization care services if not pre-approved ends when:

(A) A CE physician with privileges at the treating hospital assumes responsibility for the Enrollee's care;

(B) A CE physician assumes responsibility for the Enrollee's care through transfer;

(D) The Enrollee is discharged.

(d) Continued services to Enrollees. The CE and DBM shall take all the necessary steps to ensure continuity of care when Enrollees transition to the CE or DBM from another CE/DBM or SoonerCare program. The CE and DBM shall ensure that established Enrollee and provider relationships, current services and existing PAs and care plans will remain in place during the continuity of care period in accordance with the requirements outlined in this Section.

(1) Transition to the CE/DBM shall be as seamless as possible for Enrollees and their providers.

(2) The CE shall take special care to provide continuity of care for newly enrolled Enrollees who have physical health conditions, behavioral health conditions and/or functional needs and are under the care of existing treatment providers and whose health could be placed in jeopardy, or who could be placed at risk of hospitalization or institutionalization, if covered services are disrupted or interrupted.

(3) The DBM shall take special care to provide continuity of care for newly enrolled SoonerSelect Dental Enrollees who have oral health care needs and are under the care of existing treatment providers and whose health could be placed in jeopardy, or who could be placed at risk of hospitalization, if covered services are disrupted or interrupted.

(4) The DBM shall work with SoonerSelect and SoonerSelect Children's Specialty CEs to transition and coordinate care after a dental related emergency service pursuant to the Contract.

(5) The CE/DBM shall make transition of care policies available to Enrollees and provide instructions to Enrollees on how to access continued services during the continuity of care period.

(6) The CE/DBM shall ensure that all Enrollees are held harmless by providers for payment for any existing covered services, other than required cost sharing, during the continuity of care period.

(e) Non discrimination. The CE or DBM shall not discriminate an Enrollee on the basis of the Enrollee's health or need for medical services.

(f) Failure to comply. If the CE or DBM fails to comply with OAC 317:55-3-10, the OHCA may impose any or all the CE intermediate sanctions, found at OAC 317:55-5-10 and the CE Contract, or DBM administrative remedies, found at OAC 317:55-5-11 and the DBM Contract.