Oklahoma Health Care Authority (OHCA) announced changes to a SoonerCare member policy regarding out-of-state services which will go into effect Sept. 1.
According to OHCA, the change to the out-of-state (OOS) services policies could impact SoonerCare members who seek speciality medical care outside of Oklahoma on a regular basis. Earlier in 2019, the Oklahoma legislature passed House Bill 2341, which limited SoonerCare members to receiving services from in-state providers whenever possible.
Changes include new documentation requirements for medical care out of state that must be received within 10 days before the medical service is scheduled or prior authorization from SoonerCare will be denied except in the case of a true medical emergency. SoonerCare members will also no longer be able to “self-refer” to providers out of state and instead all requests for OOS services must be submitted by a contract provider. Those who don’t receive approval from SoonerCare could be subject to the costs of services themselves, according to OHCA.
OHCA Senior Medical Director Dr. Robert Evans said before the policy change, until SoonerCare physically received “reimbursements for meals, travel and lodging” the program didn’t know if members were receiving care out of state or not.
“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,” Evans said. “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 state’s rates.”
That’s not to say all those SoonerCare members who have a primary care doctor just on the border of Texas or Arkansas are out of luck, though. Any primary care doctor within 50 miles of the Oklahoma Border that is contracted with SoonerCare will still be available, Evans said.
“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,” Evans said. “Only those specialized medical services regularly requiring prior authorization are subject to more careful control.”
To help members find their way around the new policy, medical staff with OHCA put together a list of providers outside of Oklahoma that contract with SoonerCare and are available for complex medical-services which are not available in Oklahoma, according to OHCA Chief Executive Officer Becky Pasternik-Ikard.
“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,” she said. “Our medical staff has worked tirelessly to identify facilities and providers who will continue the level of care our members deserve.”
Dr. Mike Herndon, OHCA Chief Medical Officer, believes these changes will not only improve quality of care but maintain the control on costs of the programs.
“We also want to ensure Oklahomans are using our excellent Oklahoma providers and specialists when possible,” Herndon said. “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.”
Herndon said the policy changes also provide “transparency so providers have a clearer picture of the services available” for members while keeping the agency in compliance with regulations, state and federal.
Any SoonerCare members with questions can contact the SoonerCare Helpline at 800-987-7767 or visit okhca.org/oosmembers/.