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Part 5      ENROLLMENT PROCESS

317:25-7-25.Member enrollment process
[Revised 01-01-09]
(a) SoonerCare eligible individuals whose eligibility is based on one of the aid categories included in the program as defined in OAC 317:25-7-12 must enroll with a PCP. Parents or guardians will choose on behalf of minor members in the household. Families with more than one enrollee may choose a different PCP for each family member.
(b) Until the effective date of enrollment with a PCP, services for a newborn are reimbursed at a fee-for-service rate. Upon eligibility determination, newborns may enroll with a PCP who is in general practice, family practice or general pediatrics. Enrollment materials will advise the parent or guardian of the right to change the PCP after the effective date of enrollment.
(c) A description of the PCCM program and the PCP directory is provided by the OHCA to OKDHS for distribution to OKDHS county offices.
(d) For purposes of determining the member's choice of PCP, the most recent PCP selection received by the OHCA determines the PCP which the member is enrolled with as long as capacity is available. If capacity is not available or the member does not choose, the member is assigned according to the assignment mechanism as defined by the OHCA. A member who is eligible for SoonerCare Choice but is not assigned, may request enrollment with a PCP by contacting the SoonerCare Helpline.
(e) PCPs may not refuse an assignment, seek to disenroll a member, or otherwise discriminate against a member on the basis of age, sex, race, physical or mental disability, national origin or type of illness or condition, unless that condition can be better treated by another provider type, except that IHS, tribal or urban Indian programs may provide services to Native American IHS members consistent with federal law.

 

317:25-7-26.Automatic re-enrollment
[Revised 01-01-09]
SoonerCare members who become disenrolled from a PCP solely by virtue of becoming temporarily (for 365 days or less) ineligible for SoonerCare services, are automatically re-enrolled with their previously-selected PCP, subject to capacity. The member is notified of the automatic re-enrollment and any right to disenroll from that PCP.

 

317:25-7-27.Changing PCPs
[Revised 01-01-09]

(a) The OHCA is responsible for changing a member's enrollment from one PCP to another:

(1) without cause upon the member's request; or

(2) upon demonstration of good cause.  For purposes of this paragraph, good cause means:

(A) those members who are habitually non-compliant with the documented medical directions of the provider; or

(B) those members who pose a threat to employees, or other patients of the PCP; or

(C) as a result of a grievance determination by the OHCA; or

(D) in those cases where reliable documentation demonstrates that the physician-patient relationship has so deteriorated that continued service would be detrimental to the member, the provider or both; or

(E) the member's illness or condition would be better treated by another type of provider; or

(3) when the state imposes an intermediate sanction.

(b) A written request by the PCP to change the enrollment of a member is acted upon by the OHCA within 30 days of its receipt.  The decision to change PCPs for cause is made at the discretion of the OHCA, subject to appeals policies delineated at OAC 317:2-1.  The effective date of change is set so as to avoid the issue of abandonment.

(c) In the event a SoonerCare PCP contract is terminated by OHCA for any reason, or the PCP terminates participation in the SoonerCare program the CEO may, at his or her discretion, assign members to a participating PCP when it is determined to be in the best interests of the member whose PCP has terminated.

317:25-7-28.Disenrolling a member from SoonerCare
[Revised 09-01-15]

(a) The OHCA may disenroll a member from SoonerCare if:

(1) the member is no longer eligible for SoonerCare services;

(2) the member has been incarcerated;

(3) the member dies;

(4) disenrollment is determined to be necessary by the OHCA;

(5) the status of the member changes, rendering him/her ineligible for SoonerCare;

(6) the member is authorized to receive 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;

(7) the member becomes dually-eligible for SoonerCare and Medicare; or

(8) the member becomes covered under other primary medical insurance.

(b) The OHCA may disenroll the member at any time if the member is disenrolled for good cause, as it is defined in OAC 317:25-7-27. The OHCA will inform the PCP of any disenrollments from his or her member roster.

(c) OHCA may disenroll a member upon the PCP's request as described in (1) through (5) of this subsection.

(1) The PCP may file a written request asking OHCA to take action including, but not limited to, disenrolling a member when the member:

(A) is physically or verbally abusive to office staff, providers and/or other patients;

(B) is habitually non-compliant with the documented medical directions of the PCP; or

(C) regularly fails to arrive for scheduled appointments without cancelling and the PCP has made all reasonable efforts to accommodate the member.

(2) The request from the PCP for disenrollment of a member must include one of more of the following:

(A) documentation of the difficulty encountered with the member including the nature, extent, and frequency of abusive or harmful behavior, violence, and/or inability to treat or engage the member;

(B) identification and documentation of unique religious or cultural issues that may be effecting the PCP's ability to provide treatment effectively to the member; or

(C) documentation of special assistance or intervention offered.

(3) The PCP may not request disenrollment because of a change in the member's health status, the member's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the member's special needs except when the member's enrollment with the PCP seriously impairs his/her ability to furnish services to this member or other members.

(4) The PCP must document efforts taken to inform the member orally or in writing of any actions that have interfered with the effective provision of covered services, as well as efforts to explain what actions or language of the member are acceptable and unacceptable and the consequences of unacceptable behavior, including disenrollment from the PCP.
(5) The OHCA will give written notice of the disenrollment request to the member.

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.