Out-of-State Services Changes

 

Beginning Sept. 1, 2019 the Oklahoma Health Care Authority’s (OHCA) policies for out-of-state (OOS) services will change. These changes will continue to ensure members have access to quality care while controlling program costs.

They will not impact routine medical care for SoonerCare members.

These revisions clearly define coverage and reimbursement for services performed by providers that are physically located outside of Oklahoma.

 

What SoonerCare Members Need to Know:

Q: Will members living near Oklahoma’s borders not be able to see their regular contracted SoonerCare providers across state lines?

A: Members living near the Oklahoma state border, who regularly see a SoonerCare-contracted provider across the border, should see no changes, as long as the provider’s office is within 50 miles of the Oklahoma border. In the case of a provider’s office being more than 50 miles away from the Oklahoma border, an out of state prior-authorization will be required.

 

Q: What happens if a member is in an accident or needs emergency care while traveling in another state?

A: Emergency care in another state is still eligible for reimbursement if the care is determined to have been medically necessary.

 

Q: Will members be able to refer themselves to an out-of-state provider?

A: Self-referrals will no longer be permitted and members will be responsible for medical costs if they do not receive the proper authorization for out-of-state services. Members who  think they need out-of-state services should talk to their primary care provider.

 

Q: Will single-case agreements and contracts be allowed?

A: Single-case agreements and contracts will not be allowed under the new rule changes. SoonerCare members currently receiving OOS services through single-case agreements will be switched to regularly-contracted SoonerCare providers that OHCA medical staff have determined can provide the same level of care at OHCA’s regularly contracted rates.