Medicaid Costs and Coverage in Oklahoma

“How much is Medicaid in Oklahoma?” is a question like many others associated with SoonerCare in that every applicant will get a different answer. This is because the answer to “how much does Medicaid cost?” is largely determined by a household’s characteristics, income and services usage level. Medicaid cost estimates vary based on what kind of eligibility requirements a household meets. The costs associated with Medicaid coverage, such as copayments or premiums, vary widely between households. To truly get a picture of what services are covered by Medicaid and at what costs, recipients need to familiarize themselves with the types of Medicaid insurance available and the differences between them. An understanding of what does Medicaid not cover also plays a key role in accurately anticipating Medicaid expenses.

What services are covered by Medicaid in Oklahoma?

All types of Medicaid insurance in Oklahoma pay for certain critical primary and preventative care services as mandated by the eligibility requirements of the federal Medicaid program. Medicaid coverage also pays for a wide variety of other medical and health services. Under programmatic guidelines, however, many services are covered by Medicaid only if they are considered medically necessary. Under Medicaid insurance, the availability of some services may be governed by recipients’ ages, as well. For example, both children and legally elderly recipients are generally afforded different levels and frequencies of care.

Medicaid coverage extends extra services and allowances to children and youth enrolled in SoonerCare. In addition to the typical services covered by Medicaid for primary and preventative care, children may receive supplemental immunizations, vision services, dental and orthodontic services and procedures and expanded physical and occupational therapies. Medicaid insurance will also pay for hearing aids and treatments for speech, hearing and language disorders. Inpatient hospital services and private duty nursing care not available to other populations may be available to children, as well.

All populations enrolled in all types of Medicaid insurance are authorized to receive sick and well-patient visits. Medicaid coverage also pays for most of the lab and radiological services associated with such visits, including x-rays and blood tests. Where appropriate, Medicaid insurance pays for inpatient or outpatient hospital costs, emergency room services and essential surgeries. Again, SoonerCare coverage also pays for some or all of the related expenses such as nursing care, hospital room and board, and medical equipment and supplies. Ambulances and other emergency transportation are covered when there is a true medical emergency. Many types of Medicaid insurance also cover other forms of non-emergency transportation to and from medical appointments with authorization and documentation from a recipient’s health care provider.

Prescription drug coverage is among the critical services covered by Medicaid in Oklahoma for most populations, but a variety of limits apply. Recipients are responsible for consulting with their care providers and pharmacists to ensure they are clear on what is and is not covered. Similarly, Medicaid coverage will provide qualified and properly pre-authorized recipients with durable medical equipment and supplies.

To learn more about services covered by Medicaid, beneficiaries can download our free Medicaid guide for national program details.

SoonerCare Choice Medicaid Coverage In Oklahoma

Medicaid coverage in OK is available to certain groups, such as children younger than 19 years of age, elderly applicants 65 years of age or older, residents with disabilities, pregnant women and adults that have children younger than 19, among other groups. Some Medicaid insurance recipients in Oklahoma may be eligible to participate in the SoonerCare Choice program. SoonerCare Choice is Oklahoma Medicaid’s Primary Care Case Management (PCCM) program. Under this type of Medicaid insurance, participants are assigned “medical homes” which provide and coordinate all of their health care needs and services. SoonerCare Choice Medicaid coverage is not available to recipients who are enrolled in Medicare, who live in a nursing facility or other institutionalized setting or who belong to a health maintenance organization. Another type of Medicaid offered in Oklahoma is SoonerCare Traditional, which is available to children in the custody of the state or a Tribal organization, and those eligible for SoonerCare and Medicare, among other groups. Anyone unsure of their eligibility for Medicaid coverage should still complete the application process to see if they qualify for any type of Medicaid coverage in Oklahoma.

What does Medicaid not cover in Oklahoma?

In Oklahoma, Medicaid does not cover non-essential services that cannot be demonstrated to be medically necessary. To be covered by Medicaid insurance, services must be delivered in state by authorized providers. In some cases, advance authorization is necessary. SoonerCare coverage may refuse to pay for services which would otherwise be covered until a series of other, preferred treatments have been undertaken and proven ineffective. Emergency services will not be paid for except in genuine emergencies.

Medicaid does not cover certain costs for which recipients have other coverage. For example, in the event that a recipient has Medicare, SoonerCare will only cover co-pays, deductibles and other incidental costs not covered by the recipient’s Medicare coverage. If a recipient has Medicaid insurance and another form of insurance at the same time, the other insurance must pay everything for which it is responsible before SoonerCare will provide any payouts for the recipient’s care.

How much does Medicaid cost in Oklahoma?

Medicaid cost estimates for care and monthly premium s in Oklahoma will be different for each recipient and completing the application process. How much Medicaid costs fluctuates with the number of types of services a household uses, the severity of individual users’ medical conditions and what types of Medicaid insurance recipients have. Medicaid insurance costs are also influenced by recipients’ ability and willingness to abide by program rules. For example, services not covered by Medicaid or which are only covered in certain situations will not be paid for by SoonerCare if patients access them without special authorization. Patients who do not comply with program rules are more likely to face these unnecessary costs than recipients.

Patients with certain types of Medicaid insurance or at higher income levels may be obligated to contribute a certain amount toward their own medical expenses before Medicaid coverage will kick in each month. Copayments for services covered by Medicaid may apply in some cases, as well as small premiums for recipients in particular coverage categories. The costs of Medicaid co-pays often start as low as $1 per visit or service. For specialty or emergency services, they may range as high as $50 per service or visit. Some recipients are exempt from Medicaid costs as a result of the type of Medicaid coverage they qualified for or as the result of being extremely low income. To learn more about potential Medicaid costs, applicants can download our national Medicaid guide today.