SoonerCare CHOICE Member Handbook

This publication is authorized by the Oklahoma Health Care Authority in accordance with state and federal regulations and printed by theUniversity of Oklahoma Printing Services. Original cost of printing is $XXXX for 25,000 copies in Nov. 2003. OHCA is in compliance withTitle VI and Title VII of the 1964 Civil Rights Act and the Rehabilitation Act of 1973. The OHCA does not discriminate on basis of race, color,national origin, sex, religion, age or disability in employment or the provision of services. For additional copies, call the OHCA PublicInformation Office, 405-522-7310. 11-03

SoonerCare Helpline1-800-987-7767

or for hard-of-hearing hearing/deaf only, dial 1-800-757-5979 (TDD/TTY)Monday through Friday - 8 a.m. to 5 p.m.

Services for the hard-of-hearing/deaf, visually impaired & translation services.

Nurse Advice Line1-800-530-3002

or for the hard-of-hearing/deaf only, dial Southwestern Bell Relay Oklahoma at1-800-722-0353 TDD/TTY - 24 hours a day, seven days a week.

Translation services are available.

SoonerRide1-877-404-4500 (call 3 days before)

or for the hard-of-hearing/deaf only, dial Southwestern Bell Relay Oklahomaat 1-800-722-0353 TDD/TTY

Monday through Saturday - 8 a.m. to 5 p.m.

Ask for “Where’s My Ride?” if your ride is late or does not show up at1-800-435-1034 Monday through Saturday from 8 a.m. to 5 p.m.

or for the hard-of-hearing/deaf only, call the Oklahoma Relay Center at1-800-722-0353 TDD/TTY and request that they call the

“Where’s My Ride?” number listed above.

Care Management Division1-877-252-6002 V/TDD/TTY

Monday through Friday - 8 a.m. to 5 p.m.For members who have complex and/or unusual health care needs.

Child Abuse Hotline - 1-800-522-3511Poison Control Center - 271-5454 (OKC) or Emergency 1-800-222-1222

SoonerCare CHOICE Member Handbook

Who To Call If You Have Questions About:•Your health – call your PCP/CM or the Nurse Advice Line.• If you’re not sure it’s an emergency – call the Nurse Advice Line or your

PCP/CM.• Getting an appointment with your health care provider or Primary Care Pro-

vider/Case Manager (PCP/CM) – Call your PCP/CM’s office. If you can’t reachyour PCP/CM, call the SoonerCare Helpline.

• Transportation - Call SoonerRide (at least 3 days before) at 1-877-404-4500 orfor the hard-of-hearing/deaf only, dial 1-800-722-0353 TDD/TTY. If your ride islate or does not show up, call 1-800-435-1034 from 8 a.m. to 5 p.m., Mondaythrough Saturday or for the hard-of-hearing/deaf only, call the Oklahoma RelayCenter at 1-800-722-0353 TDD/TTY and request that they call “Where’s MyRide?” listed above.

• Changing your PCP/CM – call the SoonerCare Helpline.• Medicaid eligibility – call your local OKDHS county office.• You have moved and want to change your address – call your OKDHS county

office.• Requesting a new medical I.D. Card – call the SoonerCare Helpline.• Enrollment questions – call the SoonerCare Helpline.• General questions – call the SoonerCare Helpline.• Benefits and Services – call the SoonerCare Helpline.• Bills for health care services - call Customer Service at 1-800-522-0310 or

(405) 522-7171. For hard-of-hearing/deaf only, dial (405) 522-7179 TDD/TTY.

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Table of ContentsInside Front Cover1. Helpful Phone Numbers

I Welcome to SoonerCare -------------------------------------- Page 31. Welcome ------------------------------------------------------------------ Page 32. Eligibility ------------------------------------------------------------------- Page 33. Persons Not Eligible for SoonerCare---------------------------- Page 44. Change in Family Information -------------------------------------- Page 45. Before My SoonerCare Benefits Start --------------------------- Page 46. Medical I.D. Card ------------------------------------------------------- Page 5

II Getting Started ----------------------------------------------------Page 51. SoonerCare CHOICE ------------------------------------------------ Page 52. How the SoonerCare Helpline Can Help ----------------------- Page 53. SoonerCare CHOICE Update Period --------------------------- Page 6

III Primary Care Provider/Case Manager (PCP/CM) ------ Page 61. Choosing Your PCP/CM Page 62. Choosing Your PCP/CM If You Are Pregnant Page 73. Choosing Your PCP/CM If You Are American Indian Page 84. Changing Your PCP/CM Page 8

IV How to Get Medical Care --------------------------------------Page 91. Your First PCP/CM Visit ---------------------------------------------- Page 92. Scheduling Appointments-------------------------------------------- Page 93. Canceling Appointments ----------------------------------------------- Page 104. If You Need to See a Specialist (Referrals) ------------------------ Page 105. Services That Do Not Need a Referral (Self-Referral Services) Page 116. Emergency Care -------------------------------------------------------- Page 117. Care After an Emergency Room Visit ------------------------------- Page 128. Urgent Care --------------------------------------------------------------- Page 129. Routine Care -------------------------------------------------------------- Page 12

10. After Hours ---------------------------------------------------------------- Page 1311. Out-of-Town --------------------------------------------------------------- Page 13

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V Information About Your Covered Services and Benefits Page 13

1. List of Covered Services -------------------------------------------- Page 132. Co-payments ------------------------------------------------------------ Page 143. Prescription Benefits -------------------------------------------------- Page 154. Keep Your Children Healthy With EPSDT Services -------- Page 155. Immunizations (Shots) ----------------------------------------------- Page 156. Behavioral Health and Substance Abuse ---------------------- Page 157. Family Planning -------------------------------------------------------- Page 168. Dental Services --------------------------------------------------------- Page 169. Vision Services --------------------------------------------------------- Page 16

10. Care Management ----------------------------------------------------- Page 1611. Services That Are Not Covered------------------------------------ Page 1712. SoonerRide (Non-Emergency Transportation) --------------- Page 1813. Nurse Advice Line------------------------------------------------------ Page 18

VI You Have Rights ------------------------------------------------- Page 20

1. Members’ Rights and Responsibilities -------------------------- Page 202. Confidentiality (Right to Privacy) ------------------------------------ Page 213. Getting a Second Medical Opinion --------------------------------- Page 214. Removal From Your PCP/CM -------------------------------------- Page 215. Complaints or Problems --------------------------------------------- Page 216. Living Wills (Advance Directives)--------------------------------- Page 22

VIII Other Things to Know----------------------------------------- Page 221. If You Have Other Insurance --------------------------------------- Page 222. Help in Other Languages -------------------------------------------- Page 233. What to Do If You Get a Bill ---------------------------------------- Page 234. Questions to Ask About Care and Treatment ----------------- Page 245. Child Abuse Intervention--------------------------------------------- Page 246. Información en español ---------------------------------------------- Page 24

Inside Back Cover1. Who to Call If You Have Questions

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I Welcome to SoonerCare

Welcome to SoonerCare CHOICE! This is yourSoonerCare CHOICE Member Handbook. This book willtell you a lot about your SoonerCare benefits. Pleaseread this book carefully. What is SoonerCare CHOICE?SoonerCare is Oklahoma’s Medicaid Managed Careprogram operated by the Oklahoma Health Care Authority(OHCA). As a SoonerCare CHOICE member, you canpick a SoonerCare CHOICE provider for yourself andeach eligible member of your family. Your health careprovider is called your Primary Care Provider/CaseManager (PCP/CM).

If you have questions about your health or need medicalcare, call your PCP/CM first. In a medical emergency, call911 or go to the nearest emergency room.

Eligibility The Oklahoma Department of Human Services (OKDHS) is the state agencythat determines if you and/or a family member are eligible for SoonerCare.

Remember:! If you have a question about eligibility, call your local OKDHS office. Your

OKDHS county office will tell you when you need to re-enroll forSoonerCare.

! As long as the form is returned on time and you are re-certified by OKDHS,you will stay a member of SoonerCare.

! To check with your OKDHS Social Service Specialist every five to sixmonths about when you need to renew.

Please keep your case current!Please keep your case current!

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Persons Not Eligible for SoonerCare Certain persons are not eligible for the SoonerCare CHOICE program eventhough they may be in the Medicaid program. They are called “Exempt”. You and/or a family member will not be enrolled in the SoonerCare program if you are:

! Enrolled in an HMO (Health Maintenance Organization);! Institutionalized (in a nursing facility, long term care facility or state-run

public facility);! Enrolled in a home and community based waiver;! Eligible with both Medicaid and Medicare;! Children who are in subsidized adoptions; or! Children in state or tribal custody reported by OKDHS.

If any of the above are enrolled in the CHOICE program, please call theSoonerCare Helpline and let them know.

Change in Family Information It is important that we have your family’s most current information. Tell yourOKDHS Social Service Specialist if:

! You or a family member move,! You or a family member change telephone numbers,! You or a family member change your name,! You have a baby or put a child up for adoption, you get married or divorced,

or a member of your family dies,! Your child is placed in the custody of the OKDHS, you or a child enter a

nursing home or facility for the mentally retarded,! You get Social Security benefits or Medicare.

Before My SoonerCare Benefits Start You and/or a family member can get medical services the day after OKDHSsends OHCA your information.

How do I get services?

! You may go to a provider that will take regular Medicaid (Fee-For-Service).! If you do not have a Medical I.D. card, your provider may want to know your

Social Security Number and date of birth to check eligibility.! Call the SoonerCare Helpline and choose a PCP/CM to take care of you or

your family’s health care needs.

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Medical I.D. Card Always carry your Medical I.D. card(s) with you. If you do not have your cardwith you, it may be hard for you to get health care. The pharmacy may not wantto fill your prescription if you do not have your card. You will need to show yourcard every time you get medical or pharmacy services.

When will I get my Medical I.D. card?! A Medical I.D. card will be sent out within 7 business days after the OKDHS

sends notice to the OHCA.! Each new eligible family member will get his or her own Medical I.D. card in

the mail.! Call the SoonerCare Helpline to get a new Medical I.D. card if your card

has been lost, stolen, damaged or you have changed your name withOKDHS because of marriage, adoption, etc.

II Getting StartedSoonerCare CHOICE With SoonerCare CHOICE you can pick a health care provider for yourself andeach eligible member of your family. They are called Primary Care Provider/Case Managers (PCP/CMs).

You need to know that:

! Eligible persons for SoonerCare CHOICE must enroll in the program.! If you do not pick a PCP/CM, one will be picked for you.! You can enroll by calling the SoonerCare Helpline.! By state law, you cannot choose to stay in regular (Fee-For-Service) Medicaid.

How the SoonerCare Helpline Can Help The SoonerCare Helpline is a toll-free telephone number you can call for infor-mation and help with enrollment or to change PCP/CMs. Other Languages? TheSoonerCare Helpline can help if you speak Spanish. If you speak a languageother than English or Spanish the SoonerCare Helpline can get interpreters formany languages.

SoonerCare members should call the SoonerCare Helpline:

! After you re-certify for Medicaid,! When you are not able to contact your PCP/CM for an appointment,! To change your PCP/CM,

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! To request a new Medical I.D. card,! If you have enrollment or general information questions, and! If you need basic information about SoonerCare.

SoonerCare Helpline1-800-987-7767

or for the hard-of-hearing/deaf only, dial 1-800-757-5979 (TDD/TTY)Monday through Friday, 8 a.m. to 5 p.m.

SoonerCare CHOICE Update Period As a SoonerCare CHOICE member, you will get an update packet everyyear. During this time, you will get information about benefits, changes, and anupdated provider directory in the mail. Make sure you tell your OKDHS SocialService Specialist your new address every time you move.

III Primary Care Provider/Case Manager (PCP/CM)Choosing your PCP/CM Your health care provider is called your Primary Care Provider/Case Manageror PCP/CM. This is your “medical home.” The PCP/CM will take care of you andyour family’s basic health care needs.

You can use one provider for the whole family, or each family member canhave a different one. The providers you choose should be close to your home.

If you do not pick a PCP/CM, SoonerCare CHOICE will choose one for you.You will receive a letter in the mail with the name and address of your PCP/CMaround the time your coverage starts.

To find a PCP/CM you can look in the SoonerCare CHOICE Provider Direc-tory. You can call the SoonerCare Helpline:

! If you do not have a provider directory,! If you need the name of a provider in your area,! To find a PCP/CM’s office,! To check any enrollment choices or to enroll you and your family.

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Sometimes the PCP/CM you choose is not taking new SoonerCare CHOICEpatients. In this case, you will have to select another PCP/CM. You can changeyour PCP/CM up to four times a year by calling the SoonerCare Helpline. YourPCP/CM change request will not go into effect right away, so ask theSoonerCare Helpline when you can visit your new PCP/CM.

What does a PCP/CM do?

Your PCP/CM will:

! See you for a check-up or for other routine care,! See you when you are sick or hurt,! Refer you to a specialist if you need one, or! Admit you to the hospital or arrange for you to be admitted.

Call your PCP/CM when you or other covered family members:

! Are sick or hurt,! Need a check-up,! Need shots,! Need prescription drugs, or! Need health advice.

Who Can Be A PCP/CM?

Physician Assistants, Nurse Practitioners, or Doctors who provide primarycare services.

For an adult (over age 14): You can choose a Family Healthcare provider,Adult Healthcare provider, and females can choose a Women’s Healthcareprovider as a PCP/CM.

For a child (age 14 and under): You can choose a Children’s Healthcareprovider or a Family Healthcare provider as a PCP/CM.

If you see a provider that is not your PCP/CM for basichealth care needs, you will have to pay for the visit.

Choosing Your PCP/CM If You Are Pregnant If you are pregnant you have two choices:

! You can go to your current PCP/CM if they provide prenatal care and deliv-ery. This way you can get all your basic health care needs and your preg-nancy care in one place.

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! You can choose to go to any Medicaid health care provider (self-refer) foryour pregnancy care without a referral. This would include going to see anurse midwife. Just make sure you tell your PCP/CM who will be deliveringyour baby and where the birth will be taking place.

Choosing Your PCP/CM If You Are American Indian American Indians in the SoonerCare CHOICE program must pick a PCP/CM. If you are eligible for services at an IHS, Tribal or Urban Indian Clinic (I/T/U),you should pick a PCP/CM from the SoonerCare CHOICE Provider Directory.

How do I enroll?

! You may pick a provider from any section of the directory.! One of the sections lists IHS, Tribal & Urban Indian Clinics that participate

as SoonerCare CHOICE PCP/CMs.! To enroll with an I/T/U clinic you need to contact the SoonerCare Helpline

or the clinic of your choice.! You need to have your CDIB information for enrollment.

If you do not pick a PCP/CM, SoonerCare will pick one for you.

If you pick a provider that is not an I/T/U, you can still use the I/T/U clinicsfor medical care. You will not need a referral for services that the clinic canprovide. If you need care that the I/T/U clinic can not provide (such as contracthealth) you will need to get a referral from your PCP/CM for those services. If itis a self-referred service, you do not need a referral. For “self referral services”check the section in the handbook for more information.

Changing Your PCP/CM Call the SoonerCare Helpline to change your PCP/CM. Your PCP/CMchange request will not go into effect right away. Providers are pre-paid for a fullmonth for your care. Since SoonerCare cannot pay two providers at the sametime, your change begins at the first of the month. Sometimes this takes between15 and 45 days. Ask the SoonerCare Helpline when you can go see your newPCP/CM.

You can change four times per year. Call the SoonerCare Helpline for acurrent provider listing. If the PCP/CM you pick is not taking any more patients,you will be asked to make another choice or be placed with a different PCP/CM.Please do not pick a provider from an office that has dismissed or dropped you.

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IV How to Get Medical CareYour First PCP/CM Visit

Your PCP/CM wants to get to know you and your health care needs. Helpyour PCP/CM take good care of you by making an appointment. The first ap-pointment is your PCP/CM’s time to get to know you.

When you go to your first appointment:! Bring your shot records,! Bring the bottles for all prescription drugs that you are taking,! Tell your PCP/CM about any doctors or counselors you have seen in the

past,! Tell them if you had any surgeries or about any illness you may have had,! Tell your PCP/CM about any medical equipment you are using and the

name of the rental company,! During your visit fill out a release of “Medical Information” form. This will

allow your new PCP/CM to get your old health care records and will helpthem understand your health care needs. Check with your provider’s staffon how to get your records to your new PCP/CM, and

! Ask your PCP/CM about any health questions that you may have.

If you are going to be late or need to cancel the appointment, please call theprovider’s office and let them know at least 24 hours before your appointment.If you are using SoonerRide, also call them to cancel at least 24 hours before.

Scheduling Appointments Most PCP/CMs need you to call and make an appointment as early as pos-sible. You can call the SoonerCare Helpline to find out your PCP/CM’s name andtelephone number if you do not know it. Your PCP/CM’s office will decide if yourneeds are routine or urgent. Ask what the PCP/CM’s office hours are so you willknow when you can make appointments. Do not expect same-day appointments.

If you need a ride to your appointment see page 18 for more information.

Your PCP/CM will make every effort to see you in the following timeframes. Appointments for:

! Routine care – like shots for your baby, may take up to three weeks.! Urgent care – your PCP/CM will usually see you within 24 hours or make

arrangements for you to be seen.

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When you call to make an appointment, you should always be ready to:! Tell the staff why you need an appointment.! Give any information the staff might need such as your Medicaid case

number, etc.! Call your PCP/CM if your problem gets worse before your scheduled

appointment. Ask for advice or an earlier appointment.! Sometimes, even if you have an appointment, you may have to wait to see

your PCP/CM. He/she can be very busy with emergencies or baby deliver-ies. You may even be asked to reschedule your appointment. If you cannotwait and choose to leave please let the office staff know.

! If you have a hard time getting an appointment, call the SoonerCareHelpline. Do not call your OKDHS Social Service Specialist.

If you go to see a provider that is not your PCP/CM for basichealth care needs you will have to pay for the visit.

Canceling Appointments If something happens and you cannot keep your appointment, please call theoffice. Try to call at least 24 hours before your appointment.

If You Need to See a Specialist (Referrals) Your PCP/CM will refer you to specialists as needed. You will get a referralonly if your PCP/CM believes you need one. The specialist must be a Medicaidprovider.

! Your PCP/CM will give the specialist a referral form. You may need to callto set up the appointment. Sometimes, the PCP/CM’s office will call andset up the appointment for you.

! You must get a referral BEFORE you go to another provider. Do not askyour PCP/CM for a referral AFTER you have already seen another provider.

! If you go to another provider without a referral, you may have to pay forthose services.

! If your PCP/CM gives you a referral for a service that is not covered underthe SoonerCare CHOICE program, you will have to pay for this service.

If you feel that you need to see a specialist:! Ask your PCP/CM for a referral BEFORE going to the specialist.! If you think you need a referral but your PCP/CM will not give you one, call

the SoonerCare Helpline. They will let someone from the SoonerCareCHOICE program know what is happening.

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Services That Do Not Need a Referral (Self-Referral Services)

! Emergency Care – if you think you have a true medical emergency, go tothe nearest emergency room or call your local emergency number.

! Dental (teeth) Services if you are under age 21. Routine dental care is notcovered for adults.

! Vision (eyes) Services if you are under age 21, if the services are an eyeexam and glasses. Routine eye care is not covered for adults.

! Family Planning Services if you are under age 18.! Behavioral Health Services - but you may ask your PCP/CM to help you

get care if you need it.! OB Care –Pregnancy Care.! Indian Health Services – Members who are eligible for IHS do not have to

have a referral to go to any IHS, Tribal, or Urban Indian Health Clinic provider.! Child Abuse Exams.

Emergency Care

What is an emergency?

An emergency means:

! You could die if you don’t get the careyou need right away, or

! You could be hurt permanently (disabled).

If you have an emergency:

! Go right away to the nearest emergency room or call 911 (or your localemergency number).

! You do not need a referral to go to the emergency room.! Call your PCP/CM as soon as possible so he/she will know about the

emergency.! Your PCP/CM will need to manage your follow-up care.

Examples of emergencies are:

! Decreased consciousness or not able to respond to questions! A hard time breathing or extreme shortness of breath! Babies under 2 months old with a high fever! Extreme bleeding

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! Accidental poisoning! Broken bones! Pain and tightness in chest! Drug overdoses! Chest or head injuries

In an emergency call 911 or your local emergency phonenumber or go to the nearest hospital Emergency Room (ER).

If you are not sure you have an emergency, call:! Your PCP/CM, or! The Nurse Advice Line at 1-800-530-3002 or, for the hard-of-hearing/deaf

only, call 1-800-722-0353 (TDD/TTY), 24 hours a day, seven days a week

Care After an Emergency Room Visit If you or an eligible family member went to the emergency room, after caremay be needed. It is important to follow all after care instructions. If you needfollow-up care, call your PCP/CM.

Urgent Care (Not an Emergency) Urgent care is when you get sick or hurt and there is no immediate danger ofdeath or permanent disability. You may need attention soon, but it is not anemergency.

If you need urgent care services:

! Call your PCP/CM’s office (try to call early in the day).! Your PCP/CM must provide urgent care services for you within 24 hours.! You may also call the Nurse Advice Line. The nurses have a great deal of

information to help you.

Routine Care (Non-Urgent) Your PCP/CM will make every effort to see you within three weeks for non-urgent care. Routine care is like shots for your baby or a well child check-up. Ifyou are not able to see your PCP/CM within three weeks for routine care, pleasecall the SoonerCare Helpline for help.

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After Hours If you become ill or injured after regular office hours:

! Call your PCP/CM, or! Call the Nurse Advice Line.! Describe your problem.! Follow the instructions they give you.

Out-of-Town For emergency out-of-town care:

! Go to the nearest medical provider (doctor, clinic or hospital).! You do not need a referral from your PCP/CM if you have an emergency.

For urgent out-of-town care:! Call your PCP/CM. He/she will tell you how to get the care you need.! Call the toll-free Nurse Advice Line.

V Information about Your Covered Services and Benefits

List of Covered Services Remember! You will need to have a referral from your PCP/CM before youschedule an appointment with any other health care provider or specialist. Theonly exceptions are emergencies and for those services listed in the “Self-Referral Services” section.

The covered services listed below are available for SoonerCare CHOICEmembers. Changes in your covered services will be sent to you in the mail.

! Inpatient hospital services (limited to 24 days per year for adults.)! Provider’s (PCP/CM) office services! Some lab and x-rays! Outpatient surgery! Home health care services, limited for adults to home health visits with a

referral, durable medical equipment when medically necessary and medicalsupplies when medically necessary

! Diabetic supplies (when prescribed by a physician, physician assistant oradvanced practice nurse.) This includes one glucometer, one spring loadedlancet device and three replacement batteries per year, 100 glucose teststrips and 100 lancets per month

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! Prescription drugs are limited for adults. See the “Prescription Benefits”section for more information.

! Transportation for covered Medicaid services. See the “SoonerRide” sec-tion for more information.

! Certain durable medical equipment including oxygen, oxygen concentrators,respirators, ventilators and hyperalimentation

! Outpatient hospital services! Pregnancy/maternity services! Case management services for complex medical conditions or the severely

mentally ill! Behavioral health services! Family planning services! Podiatry services for adults and children with a referral! Vision services (members 21 and older are not covered except for treat-

ment of eye diseases or eye injuries only)! Dental services (members 21 and older are not covered except for recon-

structive dental surgery when medically necessary and for emergency ex-tractions only)

Co-payments Some services require members to share in paying the cost of their healthcare. If you are 21 years and over you may be charged a small fee called a co-payment for some services. Co-payments do not apply to members under 21.

SoonerCare CHOICE members do not have aco-payment for PCP/CM visits.

Members 21 and over will have a co-payment for:! Inpatient hospital services - $3 per day! Outpatient hospital services (includes ambulatory surgery centers) - $3 per

day per visit! Specialty care - $1 per visit! Home health care - $1 per visit! Prescription drugs

" $1 per drug costing $29.99 or less" $2 per drug costing $30.00 or more

You do NOT have to make co-payments for:! Services to pregnant women! Family planning services! Emergency services! Services if you show that you cannot pay

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Prescription Benefits (Drugs) Prescriptions that are covered may be filled at any pharmacy or drug storethat accepts Oklahoma Medicaid.

! Members 21 and over :" Receive a limited number of prescriptions per month." Should note that prescribed or over the counter contraceptives, some

drugs for HIV/AIDS, some cancer drugs, and some stop smoking cessa-tion products do not count toward the monthly limit for adults.

" Have a co-payment.

! Members under 21 have no limits or co-payments for medically necessaryprescriptions.

Always show your Oklahoma Medical I.D. Card to get your prescriptionsfilled. The pharmacy may not fill your prescription if you do not have your card.

If you are not sure a drug is covered, call your PCP/CM or the OU College ofPharmacy at 405-271-6349 or 1-800-831-8921.

Keep Your Children Healthy With EPSDT Services Make sure your children visit their PCP/CM for regular check-ups and well-child visits. Regular exams help keep your children healthy and can preventillness and disabilities. You can get your children’s “well child” check-ups frombirth to age 21. Call your PCP/CM to schedule an appointment.

Immunizations Immunizations or “shots” are important to protect your child from getting verysick. If your child misses a shot, you should call your PCP/CM to schedule anappointment to make it up. It is never too late to get shots. If you are not surethat your child has received all of the shots required by law, talk with your PCP/CM. Remember to take in your child’s most current shot record for the PCP/CMto review.

Behavioral Health and Substance Abuse You do not need a referral from your PCP/CM for behavioral health services.You should tell your PCP/CM if you are getting behavioral health or substanceabuse services. This will make it easier for your PCP/CM to manage your care.

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Family Planning Family planning can help you avoid unwanted or unplanned pregnancies. Itcan also help detect serious health problems that could affect you or your child.

! Adults (18 years or older) must get their regular family planning servicesfrom their PCP/CM, unless they have a referral.

! Adolescents (under 18 years) may get family planning services from anyfamily planning provider without a referral.

Some Family Planning benefits are:

! Family planning physical exams! Laboratory tests! Pregnancy tests and counseling! Information on birth control.

Dental Services (Teeth) It is important for children to have regular dental checkups. Dental servicesfrom a contracted provider are a self-referral service; you do not need a formfrom your PCP/CM. Members under 21 can get routine dental care. Members21 and older are limited to emergency extractions only and reconstructivedental surgery when medically necessary.

Vision Services (Eyes) If a member is younger than 21, yearly exams and glasses are covered whenprovided by a contracted provider. Vision services for eye exams and glasses donot need a referral from your PCP/CM. Vision services for adults (21 or older) arenot covered except for treatment of eye disease or eye injuries.

Care Management The Care Management team helps find medical services for SoonerCareCHOICE members who have complex and/or unusual health care needs.

Services provided by Care Management include:

! Help for health care providers with complex discharge planning! Assist PCP/CMs with finding specialty care! Work with PCP/CMs when members go from one Medicaid program to

another! Education and help for:

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" High service users," The very sick that have problems keeping up with medical care, or" High risk pregnancies.

Services That Are Not Covered SoonerCare CHOICE does not cover everything, especially for adults. Belowis a list of some common services that are not covered or paid for. This is only apartial list:

! Services that your PCP/CM or SoonerCare CHOICE does not considermedically necessary

! Any medical service when the member refuses to authorize release ofinformation which is needed to make a medical decision

! Organ transplants that are not approved by the PCP/CM and the Okla-homa Health Care Authority

! Fertility treatments! Sterilization procedures for persons under 21 years of age, mentally

incompetent, or institutionalized individuals (prohibited by federal law)! Sterilization procedures for persons 21 years of age or older without

proper consent forms! Procedures, services and supplies related to sex transformation! Supportive devices for the feet (orthotics) for adults! Cosmetic surgery! Over-the-counter drugs, medicines and supplies except contraceptive

devices and products, and diabetic supplies! Experimental procedures, drugs or treatments! Dental services for adults, except reconstructive surgery when medically

necessary and emergency extractions! Vision care and services for adults (including glasses), except services

treating diseases or injuries to the eye! Speech, Physical, Occupational Therapy for adults! Treatment for obesity.

You Will Have to Pay for Services If:

! You or your children receive services that are not covered.! You get services from another provider that requires a referral without

getting one from your PCP/CM.! You or your children get services from a provider that does not accept

Oklahoma Medicaid.

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SoonerRide (Non-Emergency Transportation)

SoonerRide provides transportation if you do not have a ride to your PCP/CM,specialist, pharmacy, or hospital.

! SoonerRide arranges to take you to services covered by Medicaid.! It is not for emergencies.! You must call at least three (3) days before your appointment to arrange for

your ride.

When are rides available?

! 6:00 a.m. to 8:00 p.m. Monday through Friday.! 8:00 a.m. to 1:00 p.m. Saturday.

To make your reservation:

! Call the toll-free number at 1-877-404-4500 from 8 a.m. to 5 p.m., Mondaythrough Saturday.

! Hard-of-hearing/deaf members only, call the Oklahoma Relay Center at1-800-722-0353 (TDD/TTY) and request they call the SoonerRide numberlisted above.

Call “Where’s My Ride?” if your ride is late or has not shown up.

! Call 1-800-435-1034 from 8 a.m. to 5 p.m., Monday through Saturday.! Hard-of-hearing/deaf members only, call the Oklahoma Relay Center at

1-800-722-0353 (TDD/TTY) and request they call the “Where’s My Ride?”number listed above.

Nurse Advice Line! This toll-free line is answered by Registered Nurses who can give you

home care suggestions and answer medical questions.! Members may call the Nurse Advice Line anytime, 24 hours a day, seven

days a week.! Translation services are offered to help you and your PCP/CM. If you

speak a language other than English and need help communicating, youcan call from your PCP/CM’s office.

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Call the Nurse Advice Line toll-free at 1-800-530-3002. For the hard-of-hearing/deaf only, dial 1-800-722-0353 (TTY/TDD).

! The Nurse Advice Line cannot give you a referral to another provider.! They give advice only.! If you are not sure if you have an emergency, call the Nurse Advice Line.

You can also call to learn about many different health topics. Here is alist of some topics you can get more information about:

! Aging ! Hearing! Alcohol Problems ! HIV Infection/AIDS! Allergies ! Hormonal Disorders! Arthritis ! Medications! Back and Neck Problems ! Mental Health! Blood and Circulatory ! Neurology! Bones, Joint and Muscles ! Newborn Care! Brain and Nervous System ! Nutrition! Cancer ! Parenting and Family Life! Cardiovascular Health ! Pregnancy and Childbirth! Child Development ! Preparing for Emergencies! Common Illnesses ! Respiratory Problems! Dental Health ! Sexually Transmitted Diseases! Diabetes ! Smoking! Digestive Disorders ! Stress/How to Cope! Drug Abuse ! Teenage Concerns! Ear, Nose andThroat ! Tests and Examinations! Exercise and Fitness ! Urinary and Genital! Family Planning ! Weight Control! Headaches

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VI You Have Rights

Members’ Rights and Responsibilities As a member of SoonerCare CHOICE you have rights. These rights in-clude but are not limited to:

! Picking a PCP/CM from the list of SoonerCare CHOICE providers. Youhave to pick one within two weeks of your application. If you do not pick aPCP/CM, SoonerCare CHOICE will pick one for you.

! Getting information in a way that is easy to understand.! Being treated with respect, dignity and having a right to privacy.! Getting information about SoonerCare CHOICE, its services and providers.! Taking part in decisions regarding your medical care.! Receiving information on available treatment options or other courses of care.! Voicing concerns about SoonerCare CHOICE or care provided.! Making advance directives (Living Wills).! Having access to your medical records as stated by federal and state laws.! Not being discriminated against by your health care provider based on your

age, sex, race, physical or mental handicap, national origin, or type/degreeof illness or condition.

! Being able to change your PCP/CM four times each year by calling theSoonerCare Helpline.

! Prompt resolutions of issues you raise.

As a member of SoonerCare CHOICE, you have responsibilities. Theseresponsibilities include but are not limited to:

! Picking a SoonerCare CHOICE PCP/CM within two weeks of your applica-tion. If you do not do this, SoonerCare CHOICE will pick one for you.

! Reading and following the rules of SoonerCare CHOICE.! Telling your OKDHS Social Services Specialist about any change in address.

You must also tell them anything that may affect your eligibility, such as ifyou got married, divorced or there were any deaths in your family.

! Following the treatment plans and guidelines that your PCP/CM gives you.! Scheduling appointments and keeping them.! Calling your PCP/CM and SoonerRide at least 24 hours before if you can-

not keep your appointment.! Providing information needed by staff to help care for you, including telling

them about your symptoms.

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Confidentiality (Right to privacy) The law says that some information is private. Certain information cannot beshared. Private things are your name, address, and health services you receive.This also includes:

! Income eligibility! Fi n a n c e s! Social conditions! Any medical information

Getting a Second Medical Opinion If your doctor wants you to have treatment or surgery, you may ask for a secondmedical opinion. Talk with your PCP/CM about a referral for another opinion.

If you are denied a second opinion, you can:

! Call the SoonerCare Helpline, which will forward a report to theSoonerCare Division, or

! Write to SoonerCare Division, Oklahoma Health Care Authority,4545 North Lincoln Blvd Suite 124, Oklahoma City, OK 73105

Removal from Your PCP/CM Your PCM/CM cannot stop seeing you as a patient because your health getsworse. However, he/she can remove you if:

! You move out of the PCP/CM’s area,! Your behavior is disruptive,! You are verbally abusive (threatening) to the PCP/CM or their office staff,! You regularly miss scheduled appointments without telling your PCP/CM at

least 24 hours before,! You have been previously dismissed by the provider or others in that office,

OR! You are no longer eligible for Medicaid and SoonerCare CHOICE.

Complaints or Problems We want you to be happy with SoonerCare CHOICE. We are here to helpyou if you have questions or problems. Talking about a problem or filing a com-plaint or formal grievance will not affect your membership or benefits withSoonerCare CHOICE.

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Call the SoonerCare Helpline if you have problems with SoonerCareCHOICE or its providers. We want to know. If you don’t like the answer you aregiven, you may request to speak with a SoonerCare Helpline supervisor. Youmay also mail us a letter telling us about your problem. The letter will need tohave the “who, what, when, where and why” of your complaint. SoonerCareCHOICE will review your letter. You will get a response to your complaint in 10days if it is medically related and 20 days if it is not. Mail your letter to:

SoonerCare CHOICEOklahoma Health Care AuthorityAttention: Docket ClerkLegal DivisionP.O. Box 18497Oklahoma City, OK 73154-0497

If you have any questions about filing a formal grievance or complaint, youmay contact the Oklahoma Health Care Authority at 405-522-7217 or for thehearing impaired only call 405-522-7182 (TDD/TTY).

Living Wills (Advance Directive) A Living Will is for persons 18 or older. A Living Will allows you to tell peoplehow you want to be treated if you cannot talk or make decisions for yourself. Youcan also list care you do or do not want to receive. For example, some people donot want to be put on life-support machines if they go into a coma.

These papers are also called “Advance Directives for Health Care. ” You maycall toll-free 1-877-283-4113 to request the “Advance Directives” form. You willget a brochure with instructions on how to fill out the form. You may also get aliving will at office supply stores, pharmacies or a lawyer’s office. Ask your fam-ily, your PCP/CM or someone you trust to help you in these matters.

VII Other Things to Know

If You Have Other Insurance If you have other medical coverage, you are required to give this informationto your OKDHS Social Service Specialist and/or to the Oklahoma Health CareAuthority. The law says this information must be shared.

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! To report other insurance or if you have questions about other insurancecoverage, you can contact your local OKDHS office or call the OHCA ThirdParty Liability Unit at 405-522-7451 or 1-800-268-5261.

! If you do have some other type of coverage in addition to your SoonerCare,you should know one important thing: You must still follow the rules of theSoonerCare program.

! To find out what insurance your SoonerCare PCP/CM may take, call yourPCP/CM’s office.

Help in other Languages in your PCP/CMs office Need help in another language? Have your PCP/CM call the Nurse AdviceLine and ask for someone who speaks your language.

! The doctor’s office can call 1-800-530-3002 for help in another languageand for the hard-of-hearing/deaf only dial 1-800-722-0350 (TDD/TTY).

What to Do If You Get a Bill In most cases, you do not receive a bill from a SoonerCare provider. Some-times, you will get a “statement” from a provider that is not a bill. If you are notsure, call the provider and ask if you have been billed.

There may be some times you are responsible for charges if:

! You or family members receive services that are not covered,! You do not have a referral from your PCP/CM for services that require a

referral, or! You or your children get services from a provider that does not accept

Oklahoma Medicaid.

If you do receive a bill, and do not think that you are responsible for thecharges, call the OHCA Customer Service at 405-522-7171 or 1-800-522-0310.Give the following information:

! The date of the service,! The amount being charged,! Who is billing you, and! Why you are being billed.

It is a good idea to have the bill with you when you call. OHCA CustomerService will help you understand what you have received and whether you couldbe responsible for payment.

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Questions to Ask About Care and Treatment It is your right as a member of SoonerCare CHOICE to take part in your careand to know what to expect. Sometimes it is hard to know what to ask. Thefollowing are a few questions that you can ask when talking to a provider regard-ing care and treatment.

When a test is suggested:! What reason is there for this test? What problem are we looking for?! What will the test tell us? If the test finds a problem, what will happen next?

When treatment or intervention is suggested:1. What is the problem? Why is this a problem? How serious is it? When do

we start treatment?2. Describe the treatment: How is it done? Will it solve the problem?3. What are the side effects?4. What else can we do: are there other types of treatment (including waiting

or doing nothing)?5. Ask questions 2, 3, and 4 about other types of treatment.

In an emergency, you may not be able to get answers to these questions.The provider should tell you how serious and urgent the situation is.

Child Abuse Intervention A parent or guardian may ask their PCP/CM to check a child for signs of abuse.Any Medicaid provider can do the exam. This service does not require a referralfrom the PCP/CM. The toll-free phone number for the Child Abuse Hotline is1-800-522-3511.

Información en español Como miembro de SoonerCare CHOICE usted puede recibir ayuda einformación en español. Si necesita ayuda para elegir un médico, o para solicitarmateriales de SoonerCare o un audio cassette en español, llame a la Línea deAyuda de SoonerCare al 1-800-987-7767. Los discapacitados del oído llamen al1-800-757-5959 (TDD/TTY).