Okla. Admin. Code § 317:55-3-1

Current through Vol. 42, No. 4, November 1, 2024

Section 317:55-3-1 - Mandatory, voluntary, and excluded populations

(a)Mandatory populations. The following SoonerCare Eligibles will be mandatorily enrolled with a CE and DBM under the Sooner Select Dental and Medical program:

(1) Expansion adults;

(2) Parents and caretaker relatives;

(3) Pregnant women;

(4) Deemed newborns;

(5) Former foster children;

(6) Juvenile justice involved children;

(7) Foster care children;

(8) Children receiving adoption assistance; and

(9) Children.

(b)Voluntary populations. SoonerCare Eligible individuals may voluntarily choose to enroll in the Sooner Select Dental and Medical program through an opt-in process if they are American Indians and/or Alaskan Natives. AI/AN populations will have the option to:

(1) Voluntarily enroll in the DBM and/or CE through an opt-in process;

(2) Enroll in a DBM and/or CE at each open enrollment period, regardless of initial selection or past disenrollment from the DBM and/or CE;

(3) When enrolled, AI/AN populations may:

(A) Receive services from an IHCP;

(B) Choose the IHCP as the Enrollee's provider, if the provider has the capacity to provide such services;

(C) Obtain services covered under the Contract from out-of-network IHCPs when the Enrollee is otherwise Eligible to receive the IHCP's services;

(D) Self-refer for services provided by IHCPs to AI/AN Enrollees;

(E) Obtain services covered under the Contract from out-of-network IHCPs when the AI/AN Enrollee is otherwise Eligible to receive the IHCP's services; and

(F) Disenroll from any DBM and/or CE at any time without cause.

(c)Excluded populations. The following individuals are excluded from enrollment in the Sooner Select program:

(1) Dual-eligible individuals;

(2) Individuals enrolled in the Medicare Savings Program, including Qualified Medicare Beneficiaries (QMB), Specified Low Income Medicare Beneficiaries (SLMB), Qualified Disabled Workers (QDW) and Qualified Individuals (QI);

(3) Persons with a nursing facility or ICF-IID level of care, except for Enrollees with a pending level of care determination;

(4) Individuals during a period of presumptive eligibility;

(5) Individuals infected with tuberculosis Eligible for tuberculosis-related services under 42 C.F.R. § 435.215;

(6) Individuals determined Eligible for SoonerCare on the basis of needing treatment for breast or cervical cancer under 42 C.F.R. § 435.213;

(7) Individuals enrolled in a § 1915(c) Waiver;

(8) Undocumented persons Eligible for emergency services only in accordance with 42 C.F.R. § 435.139;

(9) Insure Oklahoma Employee Sponsored Insurance (ESI) dependent children in accordance with the Oklahoma Medicaid State Plan;

(10) Coverage of Pregnancy-Related Services under Title XXI for the benefit of unborn children ('Soon- to-be-Sooners'), as allowed by 42 C.F.R. § 457.10; and

(11) Individuals determined Eligible for Medicaid on the basis of age, blindness, or disability.

(d)Additional eligibility criteria. For additional eligibility criteria, refer to Chapter 35 Medical Assistance for Adults and Children Eligibility Manual, 5 Eligibility and Countable Income.

Okla. Admin. Code § 317:55-3-1

Adopted by Oklahoma Register, Volume 39, Issue 10, February 1, 2022, eff. 12/21/2021

Adopted by Oklahoma Register, Volume 39, Issue 24, September 1, 2022, eff. 9/12/2022

Amended by Oklahoma Register, Volume 40, Issue 16, May 1, 2023, eff. 7/1/2023

Amended by Oklahoma Register, Volume 41, Issue 23, August 15, 2024, eff. 9/1/2024