What Does Medicaid Cover in Oklahoma?
Learn about the extensive healthcare coverage provided by Oklahoma's SoonerCare Medicaid program, including services and how to access them.
SoonerCare, Oklahoma’s Medicaid program, provides healthcare access to low-income individuals and families. Administered by the Oklahoma Health Care Authority (OHCA), SoonerCare helps eligible residents receive necessary medical attention.
General Medical and Hospital Services
SoonerCare covers general medical and hospital care, including physician visits to general practitioners and specialists. Adults typically have a limit of four outpatient physician visits per month, though additional visits are allowed for emergency medical conditions and family planning services.
Hospital services cover inpatient and outpatient care. Inpatient stays for acute illness or injury are covered. Outpatient services cover procedures not requiring an overnight stay. Emergency room care is covered for urgent situations.
Diagnostic services, such as laboratory and X-ray, are covered. These services diagnose, monitor, and guide treatment. Blood tests, imaging, and other diagnostic procedures are included.
Preventive care is covered. Vaccinations are covered. Screenings for cancers, blood pressure, and routine wellness visits are also covered.
Family planning services are available. SoonerPlan covers birth control, office visits, physical exams, and laboratory tests, including pregnancy tests and STI screenings. Tubal ligations (women 21+) and vasectomies (men 21+) are also covered. Medically necessary office visits for family planning are unlimited for members under 21; those 21 and older have a limit of four visits per month, with exceptions.
Specialized Healthcare Offerings
Specialized services are covered. Prescription drugs, including insulin, are covered. Many migraine medications are covered, some without prior authorization. Medication-assisted treatment (MAT) for opioid use disorder is covered with a $0 copay; some products may require prior authorization.
Dental services are provided, with distinct coverage for children and adults. Children under 21 receive comprehensive dental care, including routine exams, cleanings, X-rays, fluoride, and sealants. Restorative services like fillings, crowns for primary teeth, endodontics, space maintainers, and orthodontics are covered for children. For adults aged 21 and over, dental coverage is more limited, typically including emergency extractions, limited oral exams, and certain restorative procedures like fillings and dentures.
Vision services are covered, particularly for children. Eye exams and eyeglasses are covered, and treatment for eye conditions. Adult vision coverage may have limitations.
Mental health services cover outpatient behavioral health services, therapy, counseling, psychiatric evaluations, and medication management. Inpatient psychiatric evaluation and treatment are also covered when medically necessary. Screenings for depression and anxiety are available to all members.
Substance use disorder (SUD) treatment is covered. Outpatient and inpatient treatment, medical detoxification, and residential treatment (detoxification only for adults) are included. Medication-assisted treatment (MAT), counseling, and case management are covered. Prior authorization may be required for certain SUD services, such as detoxification for individuals aged 18 to 20.
Home health services provide medical care at a member’s residence. These services include skilled nursing care, therapies, and assistance from home health aides. Nursing facility services are also covered for those meeting long-term care criteria.
Durable medical equipment (DME) is provided when medically necessary for home use. Items like oxygen equipment, wheelchairs, walkers, and hospital beds are covered. Some DME, like orthotics and apnea monitors, are covered for children. Most durable medical equipment requires prior authorization from SoonerCare.
Non-emergency medical transportation (NEMT) is available through SoonerRide for appointments. This service is for routine appointments, not emergencies. Members typically schedule rides at least three business days in advance. SoonerRide offers various transportation options.
Services for Specific Enrollee Groups
SoonerCare offers specialized benefits for certain population groups. The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program is for SoonerCare members aged 20 or younger. It ensures children and adolescents receive medically necessary services. EPSDT covers medical, dental, vision, hearing, developmental screenings, and immunizations. Screenings are conducted periodically based on American Academy of Pediatrics guidelines, encompassing health and developmental history, vision, dental, hearing, and laboratory tests (e.g., lead toxicity).
Pregnant women receive maternity care services through SoonerCare. Coverage includes prenatal care, delivery, and postpartum care. Pregnant women are also eligible for SoonerSelect dental plans, offering expanded dental benefits.
Individuals with disabilities may access support through Home and Community-Based Services (HCBS) Waivers. These waivers allow eligible individuals to receive home and community-based care. Oklahoma operates several HCBS waivers. Covered services include adult day health, assistive technology, case management, habilitation, home-delivered meals, personal care, and prescription drugs. The Tax Equity and Fiscal Responsibility Act (TEFRA) program also assists children with disabilities who might not otherwise qualify for SoonerCare, by considering only the child’s income for eligibility.
SoonerCare also accommodates the healthcare needs of Native American enrollees. Members in state or tribal custody are covered under SoonerCare Traditional. Specific provisions related to tribal health services exist.
Accessing Your SoonerCare Benefits
Members can locate healthcare providers who accept SoonerCare using the official website’s provider search tool. The Oklahoma Health Care Authority (OHCA) maintains an updated directory.
Oklahoma utilizes a managed care model for many SoonerCare members through the SoonerCare Choice program. Under this model, each member is assigned or chooses a medical home (PCP). The PCP coordinates all healthcare services and provides referrals to specialists. Many members are transitioning to SoonerSelect managed care plans, offering a choice of contracted health and dental plans.
Some medical services or prescription medications require prior authorization. This ensures the service is medically necessary. Providers typically handle prior authorization, but members should be aware this may be necessary for certain treatments.
Upon enrollment, members receive a SoonerCare ID card, essential for accessing services. This card should be presented at every medical appointment to verify coverage and billing.
For questions or assistance, members can contact the SoonerCare Helpline. The helpline is available Monday through Friday, from 8:00 AM to 5:00 PM, at 800-987-7767. The OHCA website also serves as a resource for information.