Guidelines for Determining Eligibility

  • Must receive Title XIX benefits
  • Excludes those individuals who are categorized as:
    • Qualified Medicare Beneficiaries (QMB) when SoonerCare pays only the Medicare Part A and B premiums, deductibles, and co-insurance
    • Specified Low Income Medicare Beneficiaries (SLMB)
    • Qualifying Individuals (QI)
    • Individuals who are in an institution for mental disease (IMD) *for these members, contact Behavioral Health Unit, phone 800-652-2010
    • Inpatient
    • Institutionalized
    • Home and Community Based Waiver (W-HCBS) members with the exception of the In-home Supports Waiver for Children (W-IHC) and the Advantage Waiver (W-ADV).
     
  • All services are based on medical necessity.
  • All efforts to secure a temporary place to stay either by private insurance, the hospital, or a non-profit organization must be exhausted prior to seeking reimbursement for lodging and/or meals, as SoonerCare is the payer of last resort.
  • Lodging and/or meals services will only be reimbursed if the trip is for specialty care that is  at least 100 miles from the member’s home, the trip cannot be completed during SoonerRide’s operating hours, and the trip lasts 18 hours or more.
  • The provider must make every attempt to schedule an appointment that will allow the member to travel the same day within SoonerRide operating hours.
  • If the member would need to commence travel before 4 a.m. to arrive at the appointment/procedure time, then the member is eligible for lodging the night before.  If the member could not arrive home by 6:30 p.m. after the appointment/discharge time, then the member may be eligible for lodging that night. 
  • Lodging and/or Meals assistance for next-day follow-up appointments including post procedure observation will be reviewed on a case by case basis.
  • Lodging and/or Meals cannot be reimbursed for travel done more than 24 hours before or after the medical service/order.