Presentation on theme: "What is SoonerCare? SoonerCare is Oklahoma’s Medicaid program. This program helps pay some or all medical bills for many people who can't afford them."— Presentation transcript:
1What is SoonerCare?SoonerCare is Oklahoma’s Medicaid program. This program helps pay some or all medical bills for many people who can't afford them.The Oklahoma Health Care Authority (OHCA) is the state agency that administers the program.The Oklahoma Department of Human Services (OKDHS) determines financial eligibility for the program.
2What to Expect?You must apply for SoonerCare at your local DHS county office.If your eligibility is confirmed; you will receive a SoonerCare Medical I.D. cardYou can use this card as long as you are eligible for SoonerCare benefits
3Getting startedWhen enrolling in SoonerCare, you must choose a provider. This provider is called a Primary Care Provider (PCP).You also must choose a PCP for each covered member of your family.To choose your PCP call the SoonerCare Helpline
4SoonerCare Medical I.D. Card You need your medical I.D. card to get health care and your prescriptions.To keep from getting a bill, make sure you are enrolled with the provider that accepts SoonerCare before you get services.Call the SoonerCare Helpline if you did not get your card or if you lose your card.
5SoonerCare Helpline 1-800-987-7767 Choosing your PCPWhat is a Primary Care Provider (PCP)?Your PCP is the provider who takes care of your basic health care needs.The PCPs you choose should be close to your home.If you do not choose a PCP, one will be chosen for you.If the PCP you choose is not taking new SoonerCare patients, you need to choose another PCP.Who can be a PCP?A PCP can be a doctor, physician assistant, or nurse practitioner whoprovides primary care services.To find a PCP, you can look in the SoonerCare provider directory on theOklahoma Health Care Authority’s website atYou also can call the SoonerCare Helpline to ask for a printed directory.SoonerCare Helpline
6After You Choose Your PCP A letter will be sent to you at the address on file. It will tell you the name and address of your PCP and when your coverage begins with that PCP.Don’t forget to provide a reliable home address or your card will be lost or used by someone else.Changing your PCPYou can change your PCP up to four times a year by calling the SoonerCare Helpline The change will not happen right away; it may take 15 to 45 days to take place.Ask the SoonerCare Helpline when you can visit your new PCP.If you change PCPs, you will get two letters. They will tell you when coverage ends with the first PCP and begins with the next PCP.
7If You are American Indian American Indians in SoonerCare must choose a PCP by calling the SoonerCare Helpline ● TDD ● Monday-Friday 8 a.m. to 5 p.m.The Helpline will need to know the name of the clinic you are choosing. You will need to give Certificate of Degree of Indian Blood (CDIB) information for you or your child.If you do not choose a PCP, one will be chosen for you..If you enroll with an I/T/U clinic, your PCP can help you get other needed services that you can’t get at the clinic.If you do not enroll with an I/T/U clinic, you can still get your health care at that clinic. You do not need a referral.If you need care that the I/T/U clinic cannot provide, you still need to see your I/T/U PCP first and they will refer you out for additional care needs.Indian Health Service, Tribal and Urban Indian (I/T/U) health clinics are PCPsA list of I/T/U clinics are listed in your SoonerCare Choice Provider Directory.An I/T/U clinic may choose to only serve Indian members.
8As a SoonerCare Member, There are Rules you Must Follow. It is your responsibility to:► Choose a SoonerCare Choice PCP. If you do not choose one, SoonerCare will choose one for you.► Read and follow the rules of SoonerCare.► Follow the treatment plans and guidelines that your PCP gives you.► Call your medical provider and SoonerRide at least 3 days hours before any appointment.► Report changes in familyWhen you move► Call your OKDHS worker and report your new address.► Ask the worker to update your medical file with your new address.► Call the SoonerCare Helpline after a week to see if your address was updated.
9What you Must do to Keep your Benefits and your PCP You must renew SoonerCare Card every year. You can call your Oklahoma Department of Human Services (OKDHS) worker to renew by phone or go to your county DHS office.You will get a renewal form in the mail from OKDHS.You must renew on time to keep your benefits.If you do not renew on time, your benefits will stop and you will lose yourPCP.If you lose your PCP, you should call the SoonerCare Helpline to see ifyou can continue with that PCP after your renewal is approved.
10How to get medical care Your first PCP visit Your PCP wants to get to know you and your health care needs. When you go to your first visit:► Take shot records/medical history if possible► Tell your provider what drugs you are taking.► Tell your PCP about medical equipment you are using and the name of the rental company.► Ask your PCP any health questions that you may have.► Tell your PCP about other health care appointments.Making appointments► Call for an appointment as early as possible. Your PCP may not see you the same day that you call.► If you need a ride, you may call SoonerRide atWhen you call your PCP, you should always:► Tell the staff why you need an appointment.► Have your medical I.D. card available.Call your PCP’s office if your problem gets worse before your scheduled visit.► Even if you have an appointment, you may have to wait past that time to see your PCP.You should ask to reschedule if you cannot wait.
11After HoursIf you become sick or hurt after your PCP’s office is closed:Call your PCP or the Patient Advice Line after 5 p.m. weekdays or anytime on the weekends and holidays.The nurses have lots of information to help you.Describe your problem.Follow the instructions they give you.
12When to call the SoonerCare Helpline? ► If you can’t make an appointment with your PCP.► If you need to change your PCP.► If you need the name and address of your PCP.► If you have a problem with your PCP.► If you need to ask for a new medical I.D. card.► If you have general questions about SoonerCare programs.► If you need an enrollment packet or an application.► If you need to know if your address was updated.► If you think you need a referral but your PCP will not give you one► If you have a problem getting an appointment, Call the SoonerCare HelplineIf you don’t speak English, they will find someone who can translate.Do not call your OKDHS worker.
13Emergency Care What is an emergency? You could die if you don’t get the care you need right away.You could be hurt permanently (disabled).If you have an emergency:Go to the nearest emergency room or call 911 (or your local emergency number).Call your PCP as soon as possible so he or she will know about the emergency.Your PCP will need to manage your follow-up care.You do not need a referral to go to the emergency room
14If you are not sure you have an Emergency: Call your PCP during regular office hours and ask if a nurse can speak with you.After regular office hours, call the Patient Advice Line ator Relay Service 711 or (TDD)You can call these numbers before 8 a.m. or after 5 p.m. weekdaysor anytime on the weekends and holidaysThis toll-free line is answered by health care workers who cangive you home care advice and answer medical questions.► If you are not sure if you have an emergency, call your PCPand ask if a nurse can speak to you OR call the PatientAdvice Line before 8 a.m. or after 5 p.m.► The Patient Advice Line cannot refer you
15Care after an Emergency Room Visit If you went to the emergency room, you may need follow-up care. If you need follow-up or specialty care, call your PCP.Sick care (not an emergency)Sick care is when you get sick or hurt, but you are not in immediate danger of death or permanent disability. You may need attention soon, but it is not an emergency.
16SpecialistIf you go to a specialist without a referral, you may have to pay for those services.If you have questions about a covered service, please Call the SoonerCare Helpline► A referral is not a promise of payment.► If you do not keep your appointment, the specialist may NOT give you another one.
17Services That do NOT Need a Referral Family planning services.Mental health services.Help for drug and alcohol abuse.Prenatal care (pregnant women only).Child abuse exams.Emergency careDental services (teeth)Vision services (eyes)Hearing services (ears)
18Members covered services Ambulance and rides to covered SoonerCare services.Braces for members under 21 (if position of teeth is severely abnormal).Case management services for complex medical conditions or the severely mentally ill.Dental services. Members 21 and older are not covered except for emergency tooth pulling, pregnancy or following an organ transplant.Diabetic supplies (when prescribed). But with limitsDurable medical equipment, including oxygen, oxygen concentrators, respirators, ventilators and tube-feeding. (Certain conditions apply for adults.)Family planning services.Four (4) specialty visits each month.Hearing services for members under age 21. Only a physician may check for hearing loss.Help for drug and alcohol abuse.
19More ServicesHome health care services (limited for adults to 36 visits each calendar year).Inpatient hospital services.Lab and X-rays.Mental health services.Outpatient hospital services (including surgery).Podiatry (foot care) services for adults and children with a referral.Pregnancy and maternity services. This includes ultrasounds and dental care.Prescription drugs. (Most adults have limits see the “Prescription Benefits” section for more information.Vision services. Members 21 and older are not covered except for treatment of eye diseases or eye injuries.Visits to your PCP.
20Prescriptions (Medication) Always show your Oklahoma medical I.D. card to get your prescriptions.The pharmacy may not fill your prescription if you do not have your card.Members under 21 have no limits or co-payments for medicallynecessary prescriptions.• Certain over-the-counter cough and cold products are covered for children. A listof these is on our Web site at• Please call the SoonerCare Helpline if you have questions.If you are not sure a drug is covered, call your PCP or the
21Prescriptions (Medication) If you are not sure a drug is covered, call your PCP or thePharmacy Help Desk at or
22Mental health and substance abuse Do I need a referral from my PCP to see a mental health provider?No. (SoonerCare members do not need a referral for mental health or substance abuse services, but telling your PCP will make it easier to manage your care.)What mental health and substance abuse services can I get?► Medication management from a psychiatrist for adults and children.► Testing and counseling from a psychologist for children.► Services from a mental health or substance abuse agency that include:1. Individual, family or group counseling.2. Living and social skills training.3. Psychological testing.4. Case management.5. Medication review and education services
23Dental services (teeth) It is important for children to have regular dental checkups.Members under 21 can get routine dental care and braces.Coverage for braces may last up to a year from the date you got them even if you lose your coverage.Members 21 and older can get teeth pulled in an emergency.Pregnant members age 21 and older can get limited dental services.You must use a dentist who has a SoonerCare contract.
24Vision services (eyes) If a member is younger than age 21, exams and glasses from a SoonerCare Provider are covered.You do not need a referral from your PCP for eye exams and glasses.Members 21 and older are covered for treatment of eye disease or injuries with a referral from their PCP.
25Hearing services (ears) Hearing services are covered for members under age 21. You need prior authorization to get hearing aids or see an audiologist (hearing specialist).Members 21 and older are only covered for hearing evaluation.
26SoonerRide To set up a ride: Call the toll-free number at or the Relay Service at 711 or (TDD).Call “Where’s My Ride?” if your ride is late or has not shown up. CallCall the toll-free number at or the Relay Service at 711 or (TDD).(non-emergency transportation)SoonerRide can take you to scheduled visits with your PCP,specialist, pharmacy or hospital.► SoonerRide will take you to services covered by SoonerCare.► SoonerRide is not for emergencies.► You must call at least three (3) days before yourappointment to set up your ride.► Sick trips may be accepted with less notice.► You may be paid for gas you used for covered, medically needed trips.You may not be eligible for SoonerRide if you move more than 45 miles from your PCP.
27Out-of-Town/State Benefits SoonerCare will only pay providers that have contracts with SoonerCare.If you get medical services from a provider that does not have a SoonerCare contract, you will have to pay for those services.Some out-of-town/state providers have contracts with SoonerCare.This includes out-of-town/state emergency rooms.If you have questions Call SoonerCare Helpline orthe Patient Advice Line at or Relay Service 711 or (TDD) after 5 p.m. weekdays or anytime on the weekends and holidays.Call your PCP. Your PCP will tell you how to get the care you need.
28Crisis ServicesReach-out Hotline (for help with mental health or substance abuse issues)Safeline (for help with domestic violence)Teenline (for teens who need to talk to a concerned listener)(noon to midnight)Who can help me if I have other questions?Call the SoonerCare Helpline at or
29Child AbuseA parent or guardian may ask their PCP to check a child for signs of abuse.Any SoonerCare provider can do the exam.This service does not need a referral from the PCP.The toll-free phone number for the Child Abuse Hotline is
30What to do if you get a Bill You also may be billed for co-payments you did not make.If you get a bill and do not think that you have to pay for the charges, call the SoonerCare Helpline atGive the following information:► The date of the service.► The amount being charged.► Who is billing you.► Why you are being billed.It is a good idea to have the bill with you when you call.SoonerCare cannot repay you for servicesyou have paid for.In most cases, you will not get a bill from a SoonerCare provider. Sometimes, youwill get a “statement” from a provider that is not a bill. If you are not sure, call theprovider and ask if you have been billed. You may have to pay the charges.You may have to pay if:► You got services that were not covered.► You got services without the needed referral from your PCP.► You got services from a provider who does not accept SoonerCare.
31If you Have ProblemsWe want you to be happy with SoonerCare. We are here to help you if you have questions or problems. Talking about a problem or filing a complaint or an appeal on a denied service will not affect your membership or benefits.How to file a complaintCall the SoonerCare Helpline. If you have problems with SoonerCare or its providers, we want to know. The SoonerCare Helpline will make a full report of your problem. We will work with you to try to fix it.You also may write to:Oklahoma Health Care AuthorityAttention: Docket Clerk Legal DivisionP.O. Drawer 18497Oklahoma City, OK
32Help SoonerCare fight fraud and abuse What is SoonerCare (Medicaid) fraud?Fraud is when a person or group tries to get a benefit that doesn’t belong to them. An example would be money or a medical service. Basically, if someone other than the true member uses a SoonerCare card to get services, that person is committing fraud.The Oklahoma Health Care Authority sends out an Explanation of Benefits each month to selected members. This helps us identify services that were charged to members who did not get them.
33How do I Report Fraud?If you suspect SoonerCare fraud, waste or abuse, contact the SoonerCare Helpline atPlease be ready to provide as much information as possible, including:► The name of the SoonerCare member► The member’s SoonerCare card number► The name of the doctor, hospital or other health care provider► Guard your SoonerCare information carefully. Protect it as just like you do yourSocial Security number and credit cards.► Do not give your SoonerCare card number to anyone except your health care providers.Never let anyone borrow your card.► Look at your SoonerCare bill carefully. Check to see that the date of service iscorrect. Be sure you recognize the names of providers. If you don’t, call them andask them to explain the services provided.► Make sure you have prior authorization or your PCP's referral before getting servicesfrom someone other than your PCP. Besides making sure services are medicallyneeded, this step helps protect you from identity theft.► Do not ask a health care provider for medical care that you do not need.► Never sign your name to a blank form. Ask for a copy of everything you sign.Keep the copy for your records.► Don’t trust anyone who claims to know how to make SoonerCare pay for servicesor goods that SoonerCare usually does not pay for. You should avoid people whomake such claims.
34Ready to Quit Smoking?Smoking and tobacco can cause many major health problems. SoonerCare offers free stop smobenefits. Ask your health care provider about medicines or call the Oklahoma Tobacco Helpline for coaching. Products covered include nicotine patches and gum and pills that combat cravings.For the first 90 days, you can get stop smoking products as a pharmacy benefit without prior authorization. Those products will not count toward the monthly limits for members age 21 and older.After 90 days of treatment, prior authorization is needed.For more information: Oklahoma Tobacco Helpline(English)(Spanish)(TTY)
35For any other Questions please call SoonerCare Help line 1-800-987-7767