SoonerSelect FAQ for Members
Note: You may sometimes see the term “enrollee” used along with the term “member.” This means a SoonerCare member eligible to choose a SoonerSelect plan.
SoonerSelect is a health care delivery system used to coordinate health and dental care and to improve quality of care. The Oklahoma Health Care Authority (OHCA) will partner with health and dental plans to coordinate the care for most members. SoonerSelect provides Medicaid health benefits through contracted arrangements between state Medicaid agencies, health plans and dental plans.
Note: You may hear phrases such as contracted entities (CEs) or provider-led entities (PLEs) to describe health plans and dental plans.
The change in health care delivery will allow OHCA to:
- Improve health outcomes for Oklahomans
- Move toward a system where we pay providers based on the quality of care they provide to Oklahomans rather than just by service
- Improve member satisfaction
- Focus on preventive and primary care
All health/dental plans will provide the same health care services currently offered by SoonerCare. Each plan may also offer extra benefits to help you and other members be healthier.
The following SoonerCare groups will be enrolled in SoonerSelect:
- Children, including foster children
- Low-income parents
- Pregnant women
- Non-disabled adults ages 19-64
American Indian/Alaska Native members can choose to opt-in to a SoonerSelect plan but will not be required to.
If you are changing to SoonerSelect, OHCA will ask you to pick one dental plan and one health plan. You can compare the benefits of each plan and pick the right plan for you.
There are three SoonerSelect programs.
SoonerSelect Dental Program
SoonerSelect members will enroll in a dental plan. Dental plans will cover medically necessary preventive and restorative dental care. Additionally, medically necessary orthodontic services will be available for children under 21.
SoonerSelect Health Program
SoonerSelect members will enroll in a health plan. You will have a chance to choose a health plan. If you do not choose one, a plan will be assigned. Health plans will cover medically necessary prescriptions, health services and behavioral health services, except dental services.
Children’s Specialty Program
The SoonerSelect Children’s Specialty Program (CSP) will serve members involved in the juvenile justice system and those served by Oklahoma Human Services. This includes children in foster care and children receiving adoption assistance. The CSP provides medically necessary prescriptions, health care services and behavioral health services that focus on the unique health needs of the children it serves. It places special emphasis on early identification of needs and interventions.
All health/dental plans will provide SoonerSelect members with the same health care services currently offered by SoonerCare. There are no changes to pharmacy benefits. There are also no changes to eligibility requirements. Health/dental plans can offer extra benefits to help improve the health of SoonerSelect members. You will be able to compare extra benefits provided by each plan and pick the right one for you.
There is no extra cost for enrolling in a SoonerSelect plan.
Each health/dental plan will have its own network of providers. The availability of specific providers may vary from plan to plan. If you have a doctor or other provider you want to keep seeing, you should pick a health/dental plan that has your provider in the plan’s network. During sign-up, when you are picking your plans, each plan will have a provider directory on its website that you can review. OHCA member service representatives will also be available to help you with this process.
You will have the chance to pick your dental and health plans. SoonerCare representatives can help you pick the plan that best suits your needs. During the sign-up period, you can enroll by logging in to www.MySoonerCare.org or calling the SoonerCare Helpline at 800-987-7767.
Beginning late fall of 2023, you will begin receiving information on available plans and where to go to get more information on SoonerSelect programs.
Yes. You should make sure your case and contact information (address, phone number and email address) are up to date so when the time comes, you can receive critical information about SoonerSelect. You can do this by visiting www.MySoonerCare.org.
Insure Oklahoma is separate from SoonerSelect. If you are eligible for Insure Oklahoma, you are not eligible for SoonerSelect.
SoonerSelect FAQ for Providers
Oklahoma Health Care Authority (OHCA), in partnership with contracted entities (CEs) or health plans, will implement a new health care delivery model called SoonerSelect. This model will consist of health and dental CEs that will be responsible for coordinating whole-person care for enrollees.
The following SoonerCare populations must enroll in SoonerSelect:
- Low-income parents
- Pregnant women
- Adults ages 19-64
The SoonerSelect Children’s Specialty Program includes children in foster care, former foster children up to age 25, juvenile justice-involved children, and children receiving adoption assistance.
American Indian/Alaska Native members will have the option to enroll in a SoonerSelect plan.
This change will go into effect on the following dates, pending federal approval:
- February 2024: SoonerSelect dental program
- April 2024: SoonerSelect health and Children’s Specialty Program
SoonerSelect intends to streamline administrative processes for providers. For example, CEs must:
- Use a single vendor for credentialing and provider portal.
- Utilize the standardized OHCA-developed prior authorization request criteria.
- Utilize online prior authorization requests.
- Pay 90% of complete or “clean” claims within 14 days of receipt and 99% of all clean claims within 90 days of receipt.
Each CE will continue to pay providers for the services they are rendering. CEs will also pay providers who may be outside their network at the same rate as their own providers for the first 90 days after launch. After this period, all contracted providers will receive 100% of the reimbursement rate for the applicable service based on OHCA’s fee schedule until 2026. Providers will also have the opportunity to enter into value-based contracts with the CEs.
Each CE has the option to offer extra benefits to help improve the health of its members.
Examples of extra benefits similar programs in other states include:
- Program for new and expecting mothers with customized support and care.
- Expanded nutritional counseling for members with chronic conditions.
- Home meal delivery during post-hospitalization, acute in-patient stay, and postpartum.
The state invited proposals from all entities, including those that were provider-led, to serve SoonerSelect enrollees. The state reviewed all proposals and selected CEs that best fulfilled all requirements set by the state.
The key difference is the inclusion of provider-led entities (PLEs), which is mandated by state legislation. CEs must either qualify as a PLE or contract with one. To qualify as a PLE, an entity must meet at least one of the following two requirements:
- A majority of the entity's ownership is held by Medicaid providers in Oklahoma or is held by an entity that directly or indirectly owns or is under common ownership with Medicaid providers in Oklahoma.
- A majority of the entity's governing body is composed of individuals who:
- Have experience serving Medicaid members and:
- Are licensed in Oklahoma as physicians, physician assistants, nurse practitioners, certified nurse-midwives, or certified registered nurse anesthetists
- At least one member is a licensed behavioral health provider, or
- Are employed by a hospital or other medical facility licensed by and operating in Oklahoma; or an inpatient or outpatient mental health or substance abuse treatment facility or program licensed or certified by and operating in Oklahoma,
- Represent the providers or facilities described above, including, but not limited to, individuals who are employed by a statewide provider association, or
- Are non-clinical administrators of clinical practices serving Medicaid members.
- Have experience serving Medicaid members and:
You may receive a letter of intent from prospective CEs as they begin building their proposed provider network. Once contracts are awarded, providers may contact the CE directly to inquire about enrollment and credentialing. The dental CEs, DentaQuest and LIBERTY Dental, have begun reaching out to providers. The SoonerSelect health and Children’s Specialty Program CEs will begin contacting providers in the summer of 2023. OHCA will be holding meetings over the summer, providing the opportunity for providers to meet the selected contracted entities.
Under federal regulation, OHCA is prohibited from requiring a CE to execute any provider agreements beyond the number necessary to meet the needs of enrollees. A CE is also prohibited from excluding any essential community providers, which include the following provider types:
a. FQHCs and RHCs
b. Family planning providers (Title X family planning clinics and Title X “look-alike” family planning clinics)
d. County health departments or city-county health departments
e. Government-funded/operated CMHCs/CCBHCs
f. Government-operated state mental health hospitals
g. State agencies including but not limited to OJA, OSDH and OHS
h. Local, regional and state educational services agencies
i. Local health departments
j. Long-term care hospitals serving children (LTCHs-C)
k. A teaching hospital owned, jointly owned, or affiliated with and designated by the University Hospitals Authority, University Hospitals Trust, Oklahoma State University Medical Authority, or Oklahoma State University Medical Trust
l. A provider employed by or contracted with, or otherwise a member of the faculty practice plan of a public, accredited medical school in this state or a hospital/health care entity directly or indirectly owned or operated by the University Hospitals Trust or the Oklahoma State University Medical Trust
m. A provider employed by or contracted with a primary care residency program accredited by the Accreditation Council for Graduate Medical Education
n. A comprehensive community addiction recovery center
o. A hospital licensed by the state of Oklahoma, including all hospitals participating the in the Supplemental Hospital Offset Payment Program
p. Certified Community Behavioral Health Clinics (CCBHCs)
q. Other entities certified by CMS as an essential community as specified under 45 C.F.R. § 156.235
At its discretion, OHCA may add additional providers as essential community providers if the provider either offers services that are not available from any other provider within a reasonable access standard, or provides a substantial share of the total units of a particular service utilized by the enrollees within the region during the last three (3) years, and the combined capacity of other service providers in the region is insufficient to meet the total needs of the enrollees.
CEs will provide care management and population health services to coordinate the care of enrollees. CEs will offer person-centered and holistic care that identifies and addresses its enrollees' physical health, behavioral health, and community and social support needs. To help ensure models of care are developed to meet the needs of Oklahoma’s Medicaid enrollees, each CE must contract with at least one local Oklahoma provider organization.
A local Oklahoma provider organization can be any state provider association, accountable care organization, Certified Community Behavioral Health Clinic (CCBHC), Federally Qualified Health Center (FQHC), Native American tribe or tribal association, hospital or health system, academic medical institution, currently practicing licensed provider, or other local Oklahoma provider organization.
The CE will ensure all PAs for covered benefits in place on the day prior to the enrollee’s enrollment with the CE remain in place for 90 days following an enrollee’s enrollment. During this 90-day continuity of care period, PAs may not be denied on the basis that the authorizing provider is not a participating provider. Payment to non-participating providers shall be made at the current Medicaid fee schedule rate and in accordance with OHCA’s payment timeliness standards during the continuity of care period.
The contractor shall allow enrollees with an existing relationship with a non-participating provider to retain that provider during and after the transition to the contractor. The contractor shall continue to pay an enrollee’s existing providers until such time as the contractor can reasonably transfer the enrollee to a participating provider without impeding service delivery necessary to the enrollee’s health or to prevent hospitalization or institutionalization. In the event there is no participating provider available who meets the enrollee’s needs, the contractor shall allow the enrollee to retain their current provider until either the current provider becomes a participating provider or a participating provider who meets the enrollee’s needs becomes available. Notwithstanding the foregoing, enrollees shall be permitted to receive care from a non-participating provider if:
a. The only participating provider available to the enrollee does not, because of moral or religious objections, provide the service the enrollee seeks;
b. The enrollee’s PCP or other provider determines that the enrollee needs related services that would subject the enrollee to unnecessary risk if received separately and not all of these services are available within the network; or
c. OHCA determines that other circumstances warrant out-of-network treatment.
Indian Health Care Providers (IHCPs) will continue to be reimbursed by OHCA for services that are eligible for one hundred percent (100%) federal reimbursement. The CEs will make payments to IHCPs for covered services not eligible for one hundred percent (100%) federal reimbursement and provided to enrollees who are eligible to receive services through the IHCP, regardless of whether the IHCP is within the CE’s network. The reimbursement will be equal to the applicable encounter rate published annually in the Federal Register by the IHS. In the absence of a published encounter rate, the CE will reimburse the amount the IHCP would receive if the services were provided under the state plan FFS methodology.
In the event the amount the IHCP receives from the CE is less than the amount the IHCP would have received under FFS or the applicable encounter rate published annually in the FR by the IHS, the CE will make a supplemental payment to the IHCP to make up the difference. For more information, please review OHCA’s tribal health care updates.
SoonerSelect requires CEs to proactively address and improve the quality of care in rural parts of Oklahoma. All CEs must not only meet required network adequacy standards set by the state, but they must also implement innovative approaches to improve access to care for Oklahomans living in rural areas.