Co-payments and Cost Sharing
Sept. 2, 2016
Re: Cost Share Copays for SoonerCare Members – Household Limits Update
The Oklahoma Health Care Authority (OHCA) Board has authority over cost sharing in SoonerCare. Cost sharing is the portion of payment for services the member pays out of their own pocket. Such copays for approved services went into effect July 1, 2014, and have been updated. Member copays are deducted from the total cost sharing limit for each member of the household. The cost sharing limit is based upon the members' family income and is capped at five percent per month. The cost sharing limit is also applied across the members of the household and re-sets at the beginning of each month. Once the household cost sharing limit is reached, the members of the household should not be charged a copay.
There are certain groups and benefits that are exempt from such copays:
- Pregnancy related services;
- Certain American Indians and Alaskan Natives;
- Persons receiving Nursing Home care;
- Persons receiving hospice care; and
- Persons in the Oklahoma Breast and Cervical Cancer Treatment Program.
Members in Home and Community-Based Services waivers pay the following copays for prescriptions: $0.65 copay per drug costing $10.00 or less; $1.20 copay per drug costing $10.01 - $25.00; $2.40 copay per drug costing $25.01 - $50.00; $3.50 copay per drug costing $50.01 or more. Preferred generics do not have copays.
The OHCA will inform members of their household cost sharing cap amount upon eligibility determination. Members will also be informed when they have reached the total family limit. Then, they will have no more copays for the remainder of the family's current month. Members can update their information regarding a change in circumstances at any time. If the member eligibility was determined by DHS, changes should be reported to DHS. Other members may use the SoonerCare online application or may call the SoonerCare Helpline at 1-800-987-7767. An OHCA representative can review the member cost sharing information to determine the amount of cost sharing that has been processed in the current review period and verify if the member has made any overpayments in copays. If the member is identified as paying over the total limit for the month, OHCA will help with reimbursement to the member.
The member is responsible for paying all copay amounts. A provider cannot deny services based upon a member's inability to pay at the time of service. However, if a member's copay amount is left unpaid, providers can send their account to a collection agency. For a current list of copay amounts that providers are allowed to charge, please refer to the following chart, visit the OHCA SoonerCare Benefits website or contact the Sooner Care Helpline at 1-800-987-7767.
|Ambulatory Surgery Centers||$4 per visit|
|Behavioral Health and Substance Abuse Services (some services may require prior authorization)||$4 per visit;Behavioral Health Inpatient- $7.50 per day; up to a maximum of $75 per visit|
|Chemotherapy and Radiation Therapy||$4 per visit|
|Clinic services including Renal Dialysis services||$4 per visit|
|Emergency Dental services||None|
|Diabetic supplies||$4 per claim|
|Diagnostic X-ray services||$4 per visit|
|Durable Medical Equipment and supplies||$4 per claim|
|FQHC services||$4 per visit|
|Home Health services||$4 per visit|
|Immunizations||$4 per date of service|
|Inpatient hospital services (Acute Care only)||$10 per day for first seven days -$5 on the eighth day; up to a maximum of $75 per visit|
|Laboratory||$4 per visit|
|Outpatient hospital services||$4 per visit|
|Physical Therapy, Occupational Therapy, and Speech Therapy||$4 per visit|
|PCP visits and physician services||$4 per visit|
|Preventive services||$4 per visit as applicable|
|Podiatry services||$4 per visit|
|Prescription Drugs and insulin||$4 each prescription|
|Prenatal, delivery and postpartum services||None|
|Rural Health Clinic services||$4 per visit|
|Specialty Clinic visits||$4 per visit|
|Tuberculosis services||$4 per visit|