Medicaid Benefits: Online Database

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Acute Care Services

Institutional and Clinic Services

Practitioner Services

Prescription Drugs

Physical Therapy and Other Services

Products and Devices

Transportation Services

Other Services

Long-Term Care Services

Community Based Care

Institutional Care

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Benefits by State: Oklahoma (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes	$3/day			Fee for service using surgical group rates	CN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes	$1/PH Clinic service		Outpatient behavioral health services not covered for nursing facility residents	Fee for service	CN
Federally Qualified Health Center Services
Yes	$1/service			Prospective rate/visit	CN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes	$3/day up to $90/admission			Prospective payment/discharge using DRG	CN
Outpatient Hospital Services
Yes	$3/day	Specified surgical procedures and other services	Outpatient behavioral health services not covered for nursing facility residents	Fee for service using surgical group rates, ancillaries paid separately	CN
Rehabilitation Services: Mental Health and Substance Abuse
Yes			Service limits vary by type of treatment, outpatient behavioral health services not covered for nursing facility residents	Fee for service or all-inclusive daily rate	CN
Rural Health Clinic Services
Yes	$1/service			Prospective rate/visit	CN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes	$1/service			Fee for service	CN
Chiropractor Services
No
Dental Services
Yes			Limited to emergency extractions and smoking cessation counseling only for non-pregnant adults	Fee for service	CN
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes			Services limited to what a physician would provide	Fee for service	CN
Nurse Midwife Services
Yes				Fee for service	CN
Nurse Practitioner Services
Yes			4 non-emergency ambulatory visits/month included in physician limit	Fee for service	CN
Optometrist Services
Yes	$1/service		4 ambulatory visits/month included in physician limit, services limited to medical care only	Fee for service	CN
Physician Services
Yes	$1/service		1 inpatient hospital visit/day, 4 non-emergency ambulatory visits/month irrespective of setting	Fee for service	CN
Podiatrist Services
Yes	$1/service		4 non-emergency ambulatory visits/month included in physician limit, routine foot care covered only for specified systemic conditions	Fee for service	CN
Psychologist Services
No
Prescription Drugs
Prescription Drugs
Yes	$1-$2/Rx, depending on drug cost		6 Rxs/month including 3 brand Rxs, 7 additional generic Rxs/month for home and community based waiver participants	AWP-12%, plus $4.15 dispensing fee	CN
Physical Therapy and Other Services
Occupational Therapy Services
No
Physical Therapy Services
No
Services for Speech, Hearing and Language Disorders
No
Products and Devices
Dentures
No
Eyeglasses
No
Hearing Aids
No
Medical Equipment and Supplies
Yes				Fee for service	CN
Prosthetic and Orthotic Devices
Yes		Yes	Limited to specified items	Fee for service	CN
Transportation Services
Ambulance Services
Yes				Fee for service	CN
Non-Emergency Medical Transportation Services
Yes				See service-specific FN	CN
Other Services
Diagnostic, Screening and Preventive Services
Yes			Medically necessary outpatient and diagnostic x-rays and laboratory services, specified coverage criteria for mammography, limited coverage of hepatitis screening for at risk beneficiaries	Fee for service	CN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes	$1-$3/service depending on payment			Fee for service	CN
Targeted Case Management
Yes			Quantity and frequency limits vary by group served	Fee for service	CN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
Yes			Services for the following populations: 2, 4 & 8 - See service-specific FN	Dependent upon the services provided	CN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes	$1/service		36 visits/year, therapies not covered	Fee for service	CN
Hospice Care
No
Personal Care Services
Yes		Yes		Fee for service	CN
Private Duty Nursing Services
No
Program of All-Inclusive Care for the Elderly
Yes				Capitated payment	CN
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes				Prospective cost based per diem	CN
Inpatient Psychiatric Services, under age 21
Yes		Yes		Prospective cost based per diem	CN
Intermediate Care Facility Services for the Mentally Retarded
Yes			14 consecutive therapeutic leave days up to 60/year	Prospective cost based per diem with limits, leave days paid 75% of facility's rate	CN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes			5 hosp leave days/year, 7 therapeutic leave days/year	Prospective per diem based on cost and facility class, leave days paid 50% of per diem	CN
Religious Non-Medical Health Care Institution and Practitioner Services
No

Notes: This State has an approved Section 1115 Waiver from CMS under which the SoonerCare program was established to increase access to primary care for members within a partially capitated infrastructure, currently through a primary care case management model. The waiver has been amended to extend Medicaid eligibility to a number of previously uninsured individuals, including pregnant women and low-income families with children whose income is at or below 185 percent of the federal poverty level (FPL) as well as disabled children meeting Katie Beckett eligibility criteria. All SoonerCare members receive the same services and, within federal constraints, are subject to the same cost sharing requirements. This State also imposes a $.50 copayment requirement on dually eligible Medicare and Medicaid members for any service for which the State is asked to pay the coinsurance and/or deductible amount. The information appearing in the tables represents basic SoonerCare adult benefits. Coverage of the benefits is dependent upon the member meeting requirements provided in various state and federal regulations.