Press Release

August 6, 2019

Media Contact: 
Jo Stainsby, Director, Office of Public Information
Office: 405-522-7474 or Cell: 405-365-6454

Katelynn Burns, Sr. Public Information Representative
Office: 405-522-7266 or Cell: 405-397-6757

 

New policy impacts out-of-state services for SoonerCare members

OKLAHOMA CITY – Significant changes to SoonerCare’s out-of-state (OOS) services policies will take effect Sept. 1, impacting members seeking specialty medical care outside of Oklahoma.

Medical care that currently requires a prior authorization from SoonerCare will have new documentation requirements for approval that must be received 10 days prior to the medical service (except for true medical emergencies), or it will be denied. The provider performing the service will also have to be contracted with SoonerCare.

Medical staff at the Oklahoma Health Care Authority (OHCA) have constructed a list of providers outside of Oklahoma that are contracted with the agency and can provide care for complex medical services that are not available in-state.

SoonerCare members will no longer be able to self-refer to out-of-state providers. All requests for out-of-state services must be submitted by a contracted provider (M.D., D.O., A.P.R.N., or P.A.)  If the member does not receive approval from SoonerCare, members may be responsible for the costs of the services.

“Until we receive requests for reimbursement for meals, travel and lodging, SoonerCare typically does not know beforehand if a member is receiving their specialty care out of state,” said OHCA Senior Medical Director Dr. Robert Evans. “That meant we could not always ensure our members were receiving the best care for their medical needs or control the costs of their services, which is part of the prior authorization process. With these rule changes, we will be able to monitor the care our members receive as well as keep costs down by making sure providers are vetted through our regular enrollment process and agree to our state’s rates.”

“It is also important for our members who live in border communities in Oklahoma to know that if they go to see their primary care doctor, for instance, who practices in Texas or Arkansas within 50 miles of the border, they will still be able to see that doctor, as long as the doctor is contracted with SoonerCare,” said Dr. Evans. “If they travel out of state to see family and end up in the emergency room, as long as it is medically necessary, SoonerCare will cover them, as well. Only those specialized medical services regularly requiring prior authorization are subject to more careful control.”

The policy revisions define coverage and reimbursement for out-of-state services for SoonerCare members. They also spell out provider participation and prior authorization requirements including medical records requests for out-of-state providers.

The agency is moving away from single-case agreements with non-contracted providers. SoonerCare members currently receiving out-of-state services through these agreements are being transitioned to regularly-contracted SoonerCare providers who agency medical staff have determined provide the same level of care.

“The agency understands that a number of our members have very complex medical needs and we are dedicated to ensuring our members currently receiving care outside of Oklahoma have a warm, sensitive transition to a new, in-network provider,” said Becky Pasternik-Ikard, OHCA Chief Executive Officer. “Our medical staff has worked tirelessly to identify facilities and providers who will continue the level of care our members deserve.”

“We believe these changes will maintain and strengthen SoonerCare members’ access to quality care as well as control our program costs. We also want to ensure Oklahomans are using our excellent Oklahoma providers and specialists when possible,” said Dr. Mike Herndon, OHCA Chief Medical Officer. “Dr. Evans and our legal and medical staff worked for more than 18 months researching and writing these policies to be fair and rigorous to ensure the highest level of care for our members and to identify an extensive network of SoonerCare-contracted providers.

“Dr. Evans personally contacted physicians and facilities of the highest caliber to secure contracts and vet the expertise if a service was not available in Oklahoma,” said Herndon. “The policy also provides transparency so providers have a clearer picture of the services available for our members. And finally, it ensures the agency is in compliance with federal and state regulations.”

In 2019 the Oklahoma legislature passed HB 2341 which limited SoonerCare members’ services to in-state providers when possible. The Sept. 1 changes to OOS services will allow OHCA to maintain compliance with federal and state regulations.

If you are a SoonerCare member and have questions about these changes, please contact the SoonerCare Helpline at 800-987-7767 or visit http://okhca.org/OOSmembers/.

 

Summary of out-of-state services changes for SoonerCare members and providers:

  • Members who see out-of-state primary care providers will see no changes, as long as the provider is SoonerCare contracted and practices within 50 miles of the state border.
  • Members who need emergency care when out of state will see no changes, as long as the trip to the ER was determined medically necessary by SoonerCare.
  • Specialty care outside of Oklahoma for members must be with a provider contracted with SoonerCare and receive prior authorization.
  • Complete documentation for prior authorization will need to be received by OHCA 10 days before a scheduled out-of-state service unless it is a true medical emergency.
  • OHCA will no longer enter into single-case agreements with non-contracted facilities for out-of-state services.

 

 

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About the Oklahoma Health Care Authority
The Oklahoma Health Care Authority (OHCA) administers two health programs for the state. The first is SoonerCare, Oklahoma’s Medicaid program. SoonerCare works to improve the health of qualified Oklahomans by ensuring that medically necessary benefits and services are available. Qualifying Oklahomans include certain low-income children, seniors, the disabled, those being treated for breast or cervical cancer and those seeking family planning services. The second program OHCA operates is Insure Oklahoma, which assists qualifying adults and small business employees in obtaining health care coverage for themselves and their families. Currently, there are 805,273 Oklahomans enrolled in OHCA’s programs. The agency contracts with a network of 52,414 providers. For more information, visit www.okhca.org or www.insureoklahoma.org