Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 25 - Soonercare Choice › Subchapter 7 - Soonercare › Part 1 - GENERAL PROVISIONS › Section 317:25-7-2 - Sooner Care Choice: overview

Current through Vol. 41, No. 20, July 1, 2024
(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.
Added at 13 Ok Reg
					 823, eff 10-20-95 (emergency); Added at 13 Ok Reg 587, eff 11-21-95
					 (emergency); Added at 13 Ok Reg 1201, eff 1-9-96 (emergency); Added at 13 Ok
					 Reg 2519, eff 6-27-96; Amended at 13 Ok Reg 3565, eff 7-16-96 (emergency);
					 Amended at 14 Ok Reg 745, eff 12-24-96 (emergency); Amended at 14 Ok Reg 1776,
					 eff 5-27-97; Amended at 14 Ok Reg 3061, eff 7-1-97 (emergency); Amended at 15
					 Ok Reg 1511, eff 5-11-98; Amended at 17 Ok Reg 425, eff 11-2-99 (emergency);
					 Amended at 17 Ok Reg 1191, eff 5-11-00; Amended at 21 Ok Reg 2149, eff 6-25-04;
					 Amended at 24 Ok Reg 74, eff 8-2-06 (emergency); Amended at 24 Ok Reg 2057, eff
					 6-25-07; Amended at 26 Ok Reg 401, eff 1-1-09 (emergency); Amended at 26 Ok Reg
					 2074, eff 6-25-09