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 state¹s
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 members¹
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
members¹ 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.
