Community Engagement update. Plus, NEW RATE CHANGE in effect.

Work requirements update; NEW RATE CHANGE; FREE statewide DENTAL event info; and more!

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Winter 2019

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Federal comment period open RE: SoonerCare community engagement requirements

OHCA Community Engagement Amendment handout

The Oklahoma Health Care Authority (OHCA) submitted the community engagement waiver amendment to the Centers for Medicare & Medicaid Services (CMS) on Dec. 7, 2018. The federal public comment period will be open until Jan.18, 2019, at

On March 5, 2018, the governor of Oklahoma signed an executive order directing OHCA to apply for waiver and state plan amendments that would allow the state to implement community engagement requirements in the state Medicaid program (SoonerCare). In addition to the executive order, HB 2932 was passed by the state legislature, in the Oklahoma 56th Second Legislature Session, and signed into law by Gov. Mary Fallin. HB 2932 directs OHCA to pursue modifications to Medicaid eligibility criteria so that recipients of SoonerCare coverage for certain Medicaid populations are conditional upon documentation of certain education, skills training, community engagement, or job activities.

Upon approval from CMS, the state of Oklahoma will implement community engagement requirements for certain individuals related to SoonerCare (Oklahoma Medicaid) eligibility. As a condition of eligibility for SoonerCare benefits, applicants or existing members, not otherwise exempted, aged 19-50 must provide verification of employment or community engagement in specified educational, job training or job search activities for an average of 80 hours per month. SoonerCare members who fail to meet the community engagement requirements for three months during a plan year will be disenrolled from SoonerCare until requirements are met. There is a three-month grace period before members are required to provide proof of community engagement; however, the member could also have a good cause exception.

More information about the amendment is available in this handout.


Certain individuals may be exempted from the above requirements. Please visit the OHCA Policy Change Blog for details.

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Holiday observances [Agency closures]

Close up of calendar displaying Martin Luther King, Jr. Day

OHCA offices will be closed on the following dates, as they have been declared as holidays by the state of Oklahoma:

Jan. 21, 2019 - Martin Luther King, Jr. Day

Feb. 18, 2019 - Presidents' Day

We will be happy to assist you during our regular office hours.

Thank you.

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Provider Notes

Provider enrollment

Check in with us!


Please remember that all SoonerCare-contracted providers are responsible for keeping their provider file current. Please make sure your email address(es), phone number(s) and location are up to date, so you can receive all pertinent OHCA communications. Thank you.

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Policy and programs

NEW! CPT Code 80050 rate alignment in effect

At their Dec. 13, 2018, meeting, the OHCA Board voted to approve a recommendation of the State Plan Amendment Rate Committee (SPARC) for a rate change. The change aligns CPT code 80050 (general health panel) to a rate that is equal to the combined rate total of CPT codes 80053 (comprehensive metabolic panel), 84443 (thyroid stimulating hormone) and 85025 (automated complete blood count [CBC] and white blood cell count [WBC]). The new rate went into effect Jan. 1, 2019.

CPT code 80050 is a panel code that combines CPT codes 80053, 84443 and 85025 into a single code. The default rate for CPT 80050 was set in 1993 and has never changed. The Centers for Medicare & Medicaid Services (CMS) does not cover this panel code and, therefore, does not set a rate.

However, the default rates for CPT codes 80053, 85025 and 84443 have gradually decreased over time, per CMS pricing (which is set each year). As a result, the rate for the panel code is greater than the total of the individual components combined. Generally, a lab panel code reimburses the same or less than the combined individual components. This is the reason behind the proposed rate decrease, which will result in cost-savings for the agency.

As CMS pricing changes for CPT codes 80053, 84443 and 85025, the default rate set for CPT 80050 should also change to remain equal to the combined totals of the three codes.


SPARC serves the rate setting process by conducting hearings at which the public, vendors, and OHCA staff have the opportunity to provide testimony and documented evidence in support of rate recommendations. The sole purpose of SPARC is to make recommendations for changes to rates and/or methodology that require a State Plan Amendment (SPA).

State plans govern how a state administers its Medicaid and/or CHIP programs. SPAs are required to change program policy or operations, as well as to correct or update a state plan with new information.

The following SPA is now open for review and public comment:

OK SPA 19-02 Deductible and Coinsurance for Medicare Claims
OK SPA 19-02 proposes to update the reimbursement and percentage amount for the deductible and coinsurance on crossover claims to reflect current practice.

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OHCA considers more new rules

The second round of OHCA’s permanent rulemaking kicks off January 16; the first set of proposed rules were made available for public comment in December. All proposed rules can be found online at The Proposed Changes webpage is designed to give all constituents an opportunity to review and make comments regarding proposed policy changes. We encourage you to review each proposed rule and give your input.

Rules being considered include, but are not limited to:

  • Inpatient Psychiatric Services Revisions (APA WF# 18-06)
    The proposed revisions will establish a prior authorization requirement for inpatient psychiatric services for adults. Revisions will also align the time requirement of the first individual treatment by the physician to the requirement of completion of the psychiatric evaluation.
  • Oklahoma Electronic Health Records (EHR) Incentive Program Policy Revisions (APA WF# 18-10)
    The proposed revisions amend the Oklahoma EHR Incentive Program policy by changing policy regarding the required SoonerCare patient volume criteria and about documentation to support or correct the provider's EHR attestation.
  • ADvantage Waiver Revisions (APA WF# 18-21A & #18-21B)
    The proposed revisions to the ADvantage Waiver will add new language to outline requirements for personal care services and consumer directed personal assistance services and supports (CD-PASS) for case management services.
  • Developmental Disabilities Division (DDS) Revisions (APA WF# 18-22A & 18-22B)The proposed revisions to the DDS policy will reflect new service requirements for employment services through Home and Community-Based Services waivers. Revisions will also eliminate and update outdated policy in order to better align with current business practices.

As required by state statute, OHCA provides a Rule Impact Statement for each proposed rule. This includes the legal authority, possible impact to providers and/or members, projected budget impact and reason for the proposed changes. We also highlight all text changes.

Permanent rule recommendations will go to the Legislature and governor for action in the spring, with a projected implementation date of fall 2019.

OHCA Permanent Rulemaking Infographic

See what it takes to change or make a OHCA new rule.

Click the image at left for more details on OHCA's rulemaking process.

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Fluoride varnish for health care providers

Happy baby tries to brush teeth during well-child visit

February is National Children’s Dental Health Month, but SoonerCare dental professionals aren’t the only health care providers who can help kids keep their beautiful smiles.

Did you know?

SoonerCare medical providers can receive training and certification in fluoride varnish through the Smile for Life Oral Health Curriculum. Physicians (and their trained staff) must complete two online courses to be eligible for reimbursement.

Separate payment will be made to the member’s primary care provider for the application of fluoride varnish during the course of a well-child screening (EPSDT) for members aged 6 months to 60 months, per OHCA Policy 317:30-3-65.8(c). Reimbursement is limited to two applications per year by eligible providers. Check out SoonerCare Fluoride Varnish on our website for more details.

If you have questions about this benefit, please call the OHCA Provider Helpline at 1-800-522-0114, option 1.

Additionally, OHCA has helpful tip sheets to aid in caring for children's teeth. You can download them at

You can also download a fun SoonerCare Dental Coloring Sheet from our website.

We encourage providers to utilize these resources to promote the benefits of SoonerCare Dental to caretakers of pediatric members.

Statewide dental event to offer FREE services in February

OkMOM 10th Anniversary Logo

The Oklahoma Mission of Mercy, or OkMOM, is a two-day, free dental clinic offering treatment to patients that are either uninsured, under-insured or would normally not have access to dental care. 2019 marks the 10th anniversary of this life-changing event, which will take place February 1 – 2 at Oklahoma Expo Hall in the OK State Fair Park (OKC). The clinic opens at 5 a.m. each day.

During OkMOM, patients receive a dental screening to identify their needs and determine a treatment plan.  Each patient is then routed to the appropriate area(s) of the clinic: oral surgery, extractions, restorations, pediatrics and hygiene. 

There is no eligibility or income requirement, no identification or proof of citizenship required. Patients will be seen on a first-come, first-served basis.

Since 2010, Oklahoma Mission of Mercy has treated 14,454 patients, totaling more than $11 million in donated dental care.

To volunteer, donate or for more information, please visit OkMOM online at

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Protecting adult patients with pneumococcal vaccines

Doctor giving injection to an adult patient at the hospital

A recent report in the Journal of the American Board of Family Medicine (JABFM) highlighted ongoing confusion surrounding 2012 and 2014 changes to the pneumococcal vaccination schedule for adults. Only fifty percent of surveyed primary care physicians found the recommendations to be “very clear.” The remaining physicians expressed varying levels of increased confusion.

Currently the Centers for Disease Control and Prevention (CDC) recommends two pneumococcal vaccinations for patients aged 19 and older. The timing of vaccine delivery depends on several factors and is summarized in the figure below.

The CDC reports approximately 25 percent of adults younger than age 65 with an indication for pneumococcal vaccination actually received the vaccination. The OHCA provides coverage for adult vaccinations through the prescription drug benefit and medical benefit in accordance with the Advisory Committee on Immunization Practices (ACIP) guidelines. Vaccines do not count toward the monthly prescription limit.

Adult Pneumococcal Vaccine Timing chart for age 65 years and olderAdult Pneumococcal Vaccine Timing chart for ages 19-64 with underlying medical condition(s)

For additional information on this SoonerCare benefit, please contact Jacki Travers, Pharm.D., at 405-271-5935 or


Adapted from: Connecticut Immunization Coalition 

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New opioid limit reminder

Jan. 7, 2019, a new daily opioid Morphine Milligram Equivalent (MME) limit for SoonerCare pharmacy claims went into effect. This includes both short-acting and long-acting opioid formulations. Opioid MME daily totals exceeding 240 now require prior authorization (PA) with patient-specific, clinically significant reasoning why the member requires more than 240 MME per day.*

The quantity edit will progress in three (3) phases, with the final phase scheduled to occur in July 2019. The end goal is a target of 100 MME or less.

Phase 2, planned for April 2019, is a180-MME limit; Phase 3, planned for July 2019, is a 100-MME limit

Providers can also access a patient’s MME totals by consulting the Oklahoma Prescription Monitoring Program (PMP) Aware system. OHCA encourages providers to access the PMP site and begin tapering (where appropriate) members who exceed the 100 MME threshold.

If a member requires daily MME totals exceeding 100, the provider can submit an MME override request via form PHARM-111, available on the OHCA Pharmacy Forms webpage (

If you have questions regarding this quantity edit, you can reach Pharmacy Services via the OHCA Provider Helpline at 800-522-0114, option 4.


*Medications provided for Medication-Assisted Treatment (MAT) will be exempt from this policy.

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Health Care Systems Innovation

Help your patients make 2019 the year to quit tobacco

New Year’s provides the perfect motivation for your patients to reevaluate their health. Take this opportunity to discuss how they can quit or stay tobacco-free this year.

For instance, many patients have less disposable income following the holidays. Inform them of FREE resources available through the Oklahoma Tobacco Helpline, such as a free, two-week supply of patches, gum or lozenges.

Older female doctor discusses quit options with eager young woman

Encourage patients to take the Helpline’s  Readiness Quiz, which can help them assess their thoughts about taking the next step in quitting tobacco.

Finally, let your patients know they don’t have to start their quitting journey alone. The Helpline offers FREE, nonjudgmental support available 24/7.

To help spread the news, FREE promotional materials (brochures, pens ,tip cards and more) are available to order for your office at

Each new year provides an ideal moment to redefine how your patients approach their resolutions. Start a discussion with your patients and help them leave tobacco behind in 2019.  

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Electronic Health Records

Act now! EHR Program Year 2018 attestation ends in March

Professional medical team working with a computer in an office

EHR Incentive Program update

Eligible professionals (EPs) and hospitals (EHs) who have not participated in the Electronic Health Record (EHR) Incentive Program prior to 2016 are no longer able to participate in the program. 

Any EH participating in the program must attest in consecutive years. Hospitals are no longer able to skip a year.

Please note: For Program Year 2018, EPs and EHs may attest to a 90-day reporting period for Meaningful Use but are required to report on a full year for clinical quality measures, or CQMs. The only exception is for EPs in their first year of Meaningful Use. Attestation is open for all (not just first-time  Meaningful Users). The attestation deadline is March 31, 2019.

If you have any questions or concerns regarding this program, please contact the EHR Incentive Team at or by phone at 405-522-7347. You can also visit us online at

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OHCA pharmacy director receives lifetime achievement award

OHCA Pharmacy Director Nancy Nesser recently received a lifetime achievement award, The Extra Mile Award, from Artia Solutions at the inaugural Crossroads Conference.

The Extra Mile Award is a prestigious honor created to recognize former or current state Medicaid officials who have shown continual concerted effort in doing or achieving something above what is expected. Their leadership qualities are esteemed by their peers and colleagues.

Nesser was one of three award recipients. The award was voted on by fellow pharmacy directors in other state Medicaid programs and pharmaceutical representatives from across the country.

“I could not think of a more deserving person for this incredible award," said OHCA CEO Becky Pasternik-Ikard. "Nancy brings a wealth of knowledge and experience to OHCA and truly does go above and beyond in her role.”

Nesser has a bachelor’s degree in biochemistry and pharmacy, a Juris Doctorate and a Doctor of Pharmacy. She has 15 years of retail pharmacy experience and has worked at the Oklahoma Health Care Authority for 17 years.


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Regional Strategy Forums recap

Mission, Vision and Action - Symbolizing the building blocks of Strategy

In January 2018, OHCA published a strategic plan for 2018-2022 in accordance with Oklahoma statutes. Based on input from approximately 100 stakeholders and 100 agency employees, the plan articulated 10 primary strategies to drive OHCA’s programs and operations over the next five years. The plan is available at To update the plan for calendar year 2019, OHCA chose to seek additional input from stakeholders outside the metropolitan areas by holding Regional Community Strategy Forums.

OHCA held public forums in Durant, Enid, Lawton, Muskogee, Oklahoma City, Tulsa and Woodward. Approximately 200 people participated including SoonerCare members, providers and community leaders.

The forums consisted of brainstorming and small-group sessions. Groups were asked to review one of the five community-oriented strategies chosen from the plan (including objectives), suggest implementation actions and performance measures, and recommend any changes.

Each group then developed one to three implementation proposals for each strategy, with particular thought to the role that their community or organization could play in the implementation.

At the end of the forum, participants were asked to comment on anything related to the strategic plan or any other health-related subject.

In general, participants’ wishes reinforced both the vision and the strategies included in the current strategic plan. Moreover, most participants identified access and education as the main concerns for the health of rural residents and proposed a number of actions to improve one or both.

OHCA appreciates the time and input given by those who attended. We will continue to provide details and updates as the plan evolves.

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Provider Toolkit

OHCA Provider Helpline: 800-522-0114

Provider Resources

Web Alerts

Online Training

Order Publications

Statistics and Data

Newsletter Archive

Checkup Statement

Information contained within is subject to change. Be sure to check OHCA Provider LettersGlobal Messages and Web Alerts at for the most up-to-date information.

Appointment Reminders

January 10
OHCA Board Meeting

January 17
Medical Advisory Committee (MAC) Meeting

February 13
Drug Utilization Review (DUR) Board Meeting

Februaruy 14
OHCA Board Meeting

View complete OHCA calendar here.