Oklahoma Medicaid Eligibility: You Know About SoonerCare

Medicaid is a great resource for many people to receive health insurance. SoonerCare is the name given to Oklahoma’s Medicaid program. If you live in Oklahoma you may wonder, “Is there a difference between SoonerCare and Medicaid?” No. Every state has its own Medicaid program. SoonerCare is funded jointly by the federal government and Oklahoma’s state government and helps pays medical bills for people who can’t afford to do so on their own.

Even though Medicare and Medicaid may sound similar, they are actually different programs.

Medicaid and Medicare were both created in 1965, and their goal remains to ease the financial burdens of illnesses on Americans.

Essentially, Medicaid (SoonerCare) is a state and federal program that provides health coverage based on your income level.

Medicare is administered by the federal government and provides health coverage if you are 65 or older or have certain qualifying disabilities.

Although SoonerCare is funded by both the state and federal government, it is administered by the state of Oklahoma.  The Oklahoma Health Care Authority (OHCA) is the state agency that oversees SoonerCare. In Oklahoma, and in all other states, there are certain mandatory benefits that must be offered, but there is also broad leeway to determine how SoonerCare is implemented.

About 25 percent of Oklahomans use healthcare services through SoonerCare.

What Seniors Should Know About SoonerCare Includes:

• Medicaid Eligibility in Oklahoma
• How to Apply for Medicaid in Oklahoma
• Oklahoma Medicaid Application
• What Does Medicaid Cover in Oklahoma?
• Income Requirements for Oklahoma Medicaid
• How Much Does Medicare Cost in Oklahoma?
• Cost and Coverage of Medicaid in Oklahoma
• Prescription Drugs with Medicaid in Oklahoma
• Which Medicare Plan is Best in Oklahoma?
• Which Medicaid Plan Would be Best in Oklahoma?
• Dual Eligibile Medicare and Medicaid Plans in Oklahoma
• Is Oklahoma Medicaid and SoonerCare the same?
• For More Information About SoonerCare

Medicaid Eligibility in Oklahoma

To be eligible for SoonerCare, you must meet certain requirements:

• You must be an Oklahoma resident.
• Be a U.S. citizen or qualified alien (most immigrants who arrived after August 22, 1996 are barred from the program for five years).
• Meet financial income and resources limitations standards.

In general, the following groups of individuals may qualify for SoonerCare services:

• Adults with children under 19
• Children under 19 and pregnant women
• Individuals 65 and older (Medicare eligible residents in Oklahoma)
• Individuals who are blind or who have disabilities
• Women under 65 who need breast or cervical cancer treatment
• Men and women 19 and older with family planning needs (SoonerPlan)

How to Apply for Medicaid in Oklahoma

Before you start the application process, you need to have the following information available:

• Your taxable income
• Your spouse’s taxable income
• Social Security numbers and dates of birth for of everyone in your home
• Current or recent health insurance information
• Identity and citizenship information, or alien registration information.
• Income information including employer name, address and phone number, of all household members who are employed
• Amount of money received from other types of income
• Expected date of delivery and number of babies for any pregnant household member
• Current health insurance information for all household members with health insurance including company name, policy or group number, type of coverage, effective date, policy holder’s name and ID

Most SoonerCare Medicaid members can apply or renew online. If you do not have internet access, you can apply at your local Oklahoma Department of Human Services office, county health department office or an Indian health center.

Before a SoonerCare Medicaid application is approved, OHCA partners with other entities to conduct an extensive automated data search on the applicant. OHCA can then spot potential red flags before the application is even completed and request follow-up documentation to verify eligibility before membership is granted. Once an applicant is approved for Soonercare, OHCA audits the member on a daily, weekly, monthly, and quarterly basis to proactively prevent fraud and abuse.

Oklahoma Medicaid Application

To apply online, go to the Oklahoma Healthcare Authority enrollment page where you will need to create an account and get a member ID number as the first step in applying for benefits.

If you do not have Internet access, you can apply using one of these other options:

• Go to a local county office such as the Health Department or Department of Human Services. Employees in these offices can assist you in completing your on-line application.
• Go to your local library (please note that due to limited resources the library can ONLY provide the computer, they are unable to answer any specific questions about the application).
• Call 1-800-987-7767 and ask for an agency or community partner location near you.

 Applicants who want to use a paper form can download a form from the federal website or healthcare.gov. You can also call the Federally Facilitated Marketplace (FFM) at 1-800-318-2596 and request a paper application. These applications will be evaluated by the FFM, and the information will be given to OHCA.

Not all SoonerCare members can use the online application. For example, if you receive Social Security Income (SSI) payments or cash assistance Temporary Assistance for Needy Families (TANF), you must apply at your local DHS office.

If you need assistance with the online application you can call the SoonerCare helpline at 1-800-987-7767 or visit your local Community Action agency.

What Does Medicaid Cover in Oklahoma?

Under federal law, all states are required to provide the following mandatory Medicaid benefits:

• Inpatient hospital services
• Outpatient hospital services
• EPSDT: Early and Periodic Screening, Diagnostic and Treatment Services
• Nursing facility Services
• Home health services
• Physician services
• Rural health clinic services
• Federally qualified health center services
• Laboratory and X-ray services
• Family planning services
• Nurse midwife services
• Certified pediatric and nurse practitioner services
• Freestanding birth center services (when licensed or otherwise recognized by the state)
• Transportation to medical care
• Tobacco cessation counseling for pregnant women

SoonerCare covers a wide variety of healthcare services, but there are certain limitations that apply to make sure that only medically necessary services are provided.  In addition, some services are available for children only.

Additional Services for Children

• Hearing aids
• Immunizations
• Incontinence Supplies for certain children ages 4-20
• Incontinence Supplies (Spanish)
• Inpatient hospital services for patients in institutions for mental disease
• Optometric or optical services, including eyeglasses
• Orthodontics
• Other medically necessary services
• Physical and occupational therapy
• Private duty nursing
• Speech, hearing and language disorder services

The following programs may provide additional services or more restrictions to the services covered above for enrollees.

• Breast and Cervical Cancer Treatment Services (Oklahoma Cares)
• Family Planning services (SoonerPlan)
• Home and community-based services authorized under a waiver (In-Home Care)

Income Requirements for Oklahoma Medicaid

SoonerCare Income Guidelines

For 2018, applicants may qualify for SoonerCare Income Guidelines if their tax household’s Modified Adjusted Gross Income is within the following guidelines:

In addition to income, there are various eligibility and benefit packages available.  Also, if you think your income is a little too high, you should apply anyway.  Some people qualify with slightly higher incomes.

How Much Does Medicare Cost in Oklahoma?

Eligible beneficiaries in Oklahoma receive coverage through Medicare Part A at no cost if they have met eligibility requirements.  If you don’t meet requirements, then you will need to buy Part A at a cost of up to $437 per month in 2019. if you paid Medicare taxes for less than 30 quarters.  If you paid Medicare taxes for 30-39 quarters, then the standard premium will be $240 in 2019.

The 2019 standard Part B premium amount is $135.50, but it could be higher depending on a beneficiary’s income.  Part B deductible and coinsurance is $185 in 2019. After a deductible is met, you typically pay 20% of the Medicare-approved amount for most doctor services (including most doctor services while you’re a hospital inpatient), outpatient therapy, and durable medical equipment.

Medicare Part C, also known as Medicare Advantage, offers a different way to receive Medicare Part A and Part B benefits.  Private Medicare providers cover required services and often times offer enhanced coverage in exchange for a beneficiary paying a premium for the added coverage.

Part D coverage pays for prescription drugs and is also offered by Medicare-approved insurance providers at an additional premium.

Part C and Part D coverage will vary by location and provider and will also be based in part on the level of coverage.  Higher income consumers may pay more in premiums as well.

For more details on Medicare costs for 2019, go here.

Cost and Coverage of Medicaid in Oklahoma

For people who are enrolled in SoonerCare, there are no costs associated with providing care provided that enrollees meet income guidelines for various medical services. Co-pays may apply to some services. 

However, SoonerCare pays only the deductibles and a portion of the co-insurance when services are covered by Medicare. OHCA also pays the monthly Medicare Part B premium for SoonerCare members age 65 or older and for certain blind or disabled persons. If an eligible person has other medical insurance, that insurance company must be billed before SoonerCare is billed.

Prescription Drugs with Medicaid in Oklahoma

Prescription drugs that are covered by SoonerCare can be filled at any pharmacy or drugstore that accepts SoonerCare. 

For adults, there is a limit of six covered prescriptions per month and your pharmacy must give you a generic drug when one is available.  Your doctor may also need to have some prescriptions approved by SoonerCare. Prescriptions for birth control, some drugs for HIV/AIDS, some cancer drugs and some smoking cessation products will not count against your prescription limit.  There is a co-payment of $4 for each prescription.

For SoonerCare members younger than 21, there are no limits or co-payments for medically necessary prescriptions.

SoonerCare offers free smoking cessation benefits.  Covered products include nicotine patches, gums and lozenges, as well as other pills that combat cravings.

Members can get smoking cessation products as a pharmacy benefit for up to 6 months. Those products will not count toward the monthly limits for members age 21 and older. 

For more details, call the Oklahoma Tobacco Helpline at 1-800-784-8669.

Which Medicare Plan is Best in Oklahoma?

It’s extremely important to remember that no plan is created equal.  Yes,  there might be standardized Medicare supplement plans, but the prices are almost always different.

The way to determine which Medicare plan is best in Oklahoma is to shop your options.  By fully shopping your options you’ll be able to find the best plan that fits you.  Below are some considerations for finding which Medicare plan is best in Oklahoma.

• Use the Part D plan finder to enter your drugs to identify the tiers and associated copays.
• Compare the networks of primary doctors and specialists to ensure your doctor is in network
• Understand the additional benefits you may qualify for such as dental, vision, hearing, and wellness.

Once you have gone through that exercise in full, you’ll be better suited to determine which Medicare plan is best in Oklahoma for you.

Which Medicaid Plan Would be Best in Oklahoma?

Depending on your circumstances, you may qualify for various SoonerCare programs.  Those include:

SoonerCare Choice

This is a Primary Care Case Management program where each member has a medical home.  The home provider coordinates all healthcare services for those Oklahomans who qualify for the program.  Your medical home means you have one providers who sees you when needed and provides for your overall health needs.  This provider continues to treat you as long as you are his or her patient and will coordinate your care with other providers as needed.

You may qualify if you meet the following requirements:

• You qualify for SoonerCare;
• You do not qualify for Medicare;
• You do not reside in an institution such as a nursing facility;
• You are not receiving SoonerCare services through a home- and community-based waiver program;
• You are not in state or tribal custody;
• You are not in a health maintenance organization.

If you became a member using the online enrollment process, you have already chosen a medical home. If you applied by any other method you will need to choose a medical home. You must call the SoonerCare Helpline to choose your medical home at 800-987-7767. Your SoonerCare benefits will be limited if you do not choose a medical home.

You can use the same medical home for your whole family or each family member can choose a different one. Your medical home must be within 45 miles of your home to qualify for SoonerRide. SoonerRide is free transportation for non-emergency care.

For more information on SoonerCare Choice, you can download a SoonerCare Member Handbook which will provide complete enrollment and coverage details.

SoonerCare Supplemental

SoonerCare Supplemental is a plan that may help pay for Medicare cost sharing requirements if you meet low income and limited resources requirements.  It provides medical benefits to supplement Medicare Part A, Part B, Part D and cost sharing expenses, such as deductibles and co-insurance.

To apply, visit a local Oklahoma Department of Human Services office and complete an application or download the Request for Benefits form from the DHS website.  Complete the form and return it to a local DHS office.

For more information on eligibility for SoonerCare Supplemental, go here.

SoonerCare Traditional

SoonerCare Traditional is a fee-for-service plan with a statewide network of providers that includes hospitals, family practice doctors, pharmacies and durable medical equipment companies.  Members choose from contracted providers to receive any of these services.

All members are initially enrolled in SoonerCare Traditional, however only a small percentage remain in the program. They include:

• residents of long-term care facilities;
• dually eligible SoonerCare/Medicare members;
• people with private HMO coverage;
• those eligible for the Home and Community-Based Services (HCBS) waivers;
• children in state or tribal custody.

SoonerCare will not pay for services of a non-SoonerCare provider. A provider’s participation in the SoonerCare program is voluntary and SoonerCare members should ask if SoonerCare is accepted before scheduling an appointment.

SoonerPlan

SoonerPlan is a family planning program for men and women who are not enrolled in other regular SoonerCare programs.  Services are available from any contracted SoonerCare provider who offers family planning. SoonerPlan pays for family planning services (birth control), including:

• Birth control information and supplies
• Office visits and physical exams related to family planning;
• Laboratory tests related to family planning services, including pregnancy tests, Pap smears and screening for some sexually transmitted infections;
• Tubal ligations for women age 21 and older;
• Vasectomies for men age 21 and older; and
• Gardasil for males and females through age 26.

These services will be paid for as long as you are seeking a birth control method.  If you are approved, you may be eligible for SoonerPlan for up to 12 months.

Is SoonerCare Medicaid?

Yes.  SoonerCare is the name given to Oklahoma’s Medicaid program.  The two names are interchangeable.

For More Information About SoonerCare

For all questions about SoonerCare, call the Oklahoma Medicaid phone number at 800-987-7767, Monday through Friday, 8 am to 5 pm.  There is no 24-hour hotline.  If you have a medical emergency, you should call your medical home provider.

You can also visit the Oklahoma Healthcare Authority website for complete SoonerCare information.

Dual Eligibile Medicare and Medicaid Plans in Oklahoma

The term dual eligible means that people are covered by both Medicare and Medicaid at the same time.  In addition to qualifying for Medicaid, people usually qualify for Medicare Part A, Medicare Part B and a Medicare Savings Program that may pay for Medicare deductibles, coinsurance, and copayments.

The four kinds of Medicare Savings Programs are the Qualified Medicare Beneficiary Program, the Specified Low-Income Medicare Beneficiary Program, the Qualifying Individual Program and the Qualified Disabled and Working Individuals Program.  To see if you qualify for any of these programs, contact a SoonerCare office or call us at 844-431-1832.