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Part 3      ENROLLMENT CRITERIA

317:25-7-10.Enrollment with a Primary Care Provider
[Revised 01-01-09]

(a) All SoonerCare Choice members described in OAC 317:25-7-12 may enroll with a PCP. SoonerCare Choice applicants have the opportunity to select a PCP during the application process. Enrollment with a PCP may begin any day of the month.

(1) The OHCA offers all members the opportunity to choose a PCP from a directory which lists available PCPs.

(2) When a notice of PCP enrollment is sent to a member, the member is advised of the right to change the PCP at any time.

(b) Members may receive services from the PCP or from a provider to which the member has been referred by the PCP. Notwithstanding this provision, subject to limitations which may be placed on services by the OHCA, members may self refer for preventive or primary care services rendered by another SoonerCare contracted provider, outpatient behavioral health agency services, vision services for children, dental services, child abuse/sexual abuse examinations, prenatal and obstetrical services, family planning services, services delivered to Native Americans at IHS, tribal, or urban Indian clinics, and emergency physician and hospital services.

317:25-7-11.Geographic coverage areas
[Revised 6-25-04]
The PCCM managed care program is statewide.

317:25-7-12.Enrollment/eligibility requirements
[Revised 01-01-09]
(a) EligibleSoonerCaremembers mandatorily enrolled in SoonerCare Choice include persons categorically related to AFDC, Pregnancy-related services and Aged, Blind or Disabled who are not dually-eligible for SoonerCare and Medicare.
(b) Children in foster care may voluntarily enroll into SoonerCare Choice.
317:25-7-13.Enrollment ineligibility
[Revised 09-01-15]

Members in certain categories are excluded from participation in the SoonerCare Choice program. All other members are enrolled in the SoonerCare Choice program and subject to the provisions of this Subchapter. Members excluded from participation in SoonerCare Choice include:

(1) Individuals receiving services in a nursing facility, in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) or through a Home and Community Based Waiver.

(2) Individuals privately enrolled in an HMO.

(3) Individuals who would be traveling more than 45 miles or an average of 45 minutes to obtain primary care services.

(4) Individuals in the former foster care children's group (see OAC 317:35-5-2).

(5) Individuals who are eligible for SoonerCare solely due to presumptive eligibility.

(6) Non-qualified or ineligible aliens.

(7) Children in subsidized adoptions.

(8) Individuals who are dually-eligible for SoonerCare and Medicare.

(9) Individuals who are in an Institution for Mental Disease (IMD).

(10) Individuals who have other primary medical insurance.

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.