(a) Definitions. The following words and terms, when used in subsection (c) of this Section, shall have the following meaning, unless the context clearly indicates otherwise:
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(1)
"Fee-for-service contract" means the provider agreement specified in OAC
317:30-3-2. This contract is the contract between the Oklahoma Health Care Authority and medical providers which provides for a fee with a specified service involved.
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(2)
"Within the scope of services" means the set of covered services defined at OAC
317:25-7 and the provisions of the SoonerCare Choice contracts in the SoonerCare Program.
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(3)
"Outside of the scope of the services" means all medical benefits outside the set of services defined at OAC
317:25-7 and the provisions of the SoonerCare Choice contracts in the SoonerCare Program.
(b) Assignment in fee-for-service. The OHCA's Medicaid State Plan provides that participation in the medical program is limited to providers who accept, as payment in full, the amounts paid by OHCA plus any deductible, coinsurance, or co-payment required by the State Plan to be paid by the member and make no additional charges to the member or others.
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(1) OHCA presumes acceptance of assignment upon receipt of an assigned claim. This assignment, once made, cannot be rescinded, in whole or in part by one party, without the consent of the other party.
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(2) Once an assigned claim has been filed, the member must not be billed and the member is not responsible for any balance except the amount indicated by OHCA. The only amount a member may be responsible for is a co-payment, or the member may be responsible for services not covered under the medical programs. In any event, the member should not be billed for charges on an assigned claim until the claim has been adjudicated or other notice of action received by the provider. Any questions regarding amounts paid should be directed to OHCA, Provider Services.
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(3) When potential assignment violations are detected, the OHCA will contact the provider to assure that all provisions of the assignment agreement are understood. When there are repeated or uncorrected violations of the assignment agreement, the OHCA is required to suspend further payment to the provider.
(c) Assignment in SoonerCare. Any provider who holds a fee for service contract and also executes a contract with a provider in the SoonerCare Choice program must adhere to the rules of this subsection regarding assignment.
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(1) If the service provided to the member is outside of the scope of the services outlined in the SoonerCare Contract, then the provider may bill or seek collection from the member.
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(2) In the event there is a disagreement whether the services are in or out of the scope of the contracts referenced in (1) of this subsection, the Oklahoma Health Care Authority shall be the final authority for this decision. The provider seeking payment under the SoonerCare Program may appeal to OHCA under the provisions of OAC 317:2-1-2.1.
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(3) Violation of this provision shall be grounds for a contract termination in the fee-for-service and SoonerCare programs.
(d) Cost Sharing-Copayment. Section 1902(a)(14) of the Social Security Act permits states to require certain members to share some of the costs of SoonerCare by imposing upon them such payments as enrollment fees, premiums, deductibles, coinsurance, co-payments, or similar cost sharing charges. OHCA requires a co-payment of some SoonerCare members for certain medical services provided through the fee for service program. A co-payment is a charge which must be paid by the member to the service provider when the service is covered by SoonerCare. Section 1916(e) of the Act requires that a provider participating in the SoonerCare program may not deny care or services to an eligible individual based on such individual's inability to pay the co-payment. A person's assertion of their inability to pay the co-payment establishes this inability. This rule does not change the fact that a member is liable for these charges and it does not preclude the provider from attempting to collect the co-payment.
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(1) Co-payment is not required of the following members:
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(A) Individuals under age 21. Each member's date of birth is available on the REVS system or through a commercial swipe card system.
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(B) Members in nursing facilities and intermediate care facilities for the mentally retarded.
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(C) Pregnant women.
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(D) Home and Community Based Service waiver members except for prescription drugs.
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(E) Native Americans providing documentation of ethnicity in accordance with
317:35-5-25 who receive items and services furnished by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization or through referral under contract health services.
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(2) Co-payment is not required for the following services:
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(A) Family planning services. Includes all contraceptives and services rendered.
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(B) Emergency services provided in a hospital, clinic, office, or other facility.
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(3) Co-payments are required in an amount not to exceed the federal allowable for the following:
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(A) Inpatient hospital stays.
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(B) Outpatient hospital visits.
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(C) Ambulatory surgery visits including free-standing ambulatory surgery centers.
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(D) Encounters with the following rendering providers:
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(i) Physicians,
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(ii) Advanced Practice Nurses,
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(iii) Physician Assistants,
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(iv) Optometrists,
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(v) Home Health Agencies,
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(vi) Certified Registered Nurse Anesthetists,
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(vii) Anesthesiologist Assistants,
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(viii) Durable Medical Equipment providers, and
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(ix) Outpatient behavioral health providers.
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(E) Prescription drugs.
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(i) Zero for preferred generics.
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(ii) $0.65 for prescriptions having a SoonerCare allowable payment of $0.00-$10.00.
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(iii) $1.20 for prescriptions having a SoonerCare allowable payment of $10.01-$25.00.
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(iv) $2.40 for prescriptions having a SoonerCare allowable payment of $25.01-$50.00.
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(v) $3.50 for prescriptions having a SoonerCare allowable payment of $50.01 or more.
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(F) Crossover claims. Dually eligible Medicare/SoonerCare members must make a co-payment in an amount that does not exceed the federal allowable per visit/encounter for all Part B covered services. This does not include dually eligible HCBS waiver members.
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(4) Aggregate cost-sharing liabilities in a given calendar year may not exceed 5% of the member's gross annual income.