ModifiedOklahoma Health Care AuthorityPolicy 0938

Alternative Benefit Plan

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This policy governs Oklahoma Alternative Benefit Plan coverage, including essential health benefits, benefit limits, authorization requirements, provider qualifications, and benefit substitutions or duplications.

Policy Summary

PayerOklahoma Health Care Authority

PolicyAlternative Benefit Plan

Policy CodePolicy N/A

Change TypeModified

Effective DateJuly 1, 2021

Next Review DateN/A

Key ActionObtain prior authorization for imaging, including CT scans, PET scans, and MRIs.

SourceLink

POLICY UPDATE CHANGES

Substance use disorder outpatient and inpatient services were revised within Transmittal Number TN-21-0014, effective July 1, 2021.

Medication-assisted treatment, infusion therapy, and multiple dental benefits were revised within TN-21-0014 effective July 1, 2021.

10Essential health benefit categories

4/monthPrimary care and specialty visit limit

15/yearOutpatient rehabilitation limit

4Adult dental benefits not included

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ModifiedOklahoma Health Care AuthorityPolicy 0938

Alternative Benefit Plan

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Sign up for Oklahoma Health Care Authority Policy 0938 alerts

Get alerted when Policy 0938 changes without checking for updates manually.

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Policy Summary

PayerOklahoma Health Care Authority

PolicyAlternative Benefit Plan

Policy CodePolicy N/A

Change TypeModified

Effective DateJuly 1, 2021

Next Review DateN/A

Key ActionObtain prior authorization for imaging, including CT scans, PET scans, and MRIs.

SourceLink

POLICY UPDATE CHANGES

Substance use disorder outpatient and inpatient services were revised within Transmittal Number TN-21-0014, effective July 1, 2021.

Medication-assisted treatment, infusion therapy, and multiple dental benefits were revised within TN-21-0014 effective July 1, 2021.

10Essential health benefit categories

4/monthPrimary care and specialty visit limit

15/yearOutpatient rehabilitation limit

4Adult dental benefits not included

17Other Section 1937 benefits provided

7Benefits requiring prior authorization

Covered Benefits and Limitations

Ambulatory patient services

Covered ambulatory patient services are subject to the following limits and authorization rules.

Ambulatory services: The service must be a covered ambulatory benefit and must comply with the applicable visit or testing limit.Primary care visits: 4 visits/month; specialty visits: 4 visits/month; other practitioner office visits: 4 visits/month for PA and APRN visits; allergy testing: 60 tests/3 years

Authorization is required in excess of applicable limits; stated limits may be exceeded based on medical necessity.

Emergency services

Emergency services are covered without an authorization requirement.

Emergency services: The service must be emergency room care, emergency transportation/ambulance, or urgent care center services.None stated

Provider must meet Medicaid State Plan qualifications.

Hospitalization

Hospitalization benefits are covered subject to service-specific authorization and scope requirements.

Hospitalization: Inpatient hospital services and inpatient physician and surgical services are covered; inpatient physician services are limited to one visit per day per physician, while inpatient surgical services have no limit.One inpatient physician visit per day per physician; inpatient surgical services: no limit

Authorization is required in excess of limitation, and limits may be exceeded based on medical necessity. Organ transplantation and reconstructive surgery have separate requirements.

Maternity and newborn care

Maternity and newborn care are covered under the referenced State Plan provisions.

Maternity and newborn care: Prenatal and postnatal care and delivery and inpatient services for maternity care are covered.None stated

The applicable State Plan provisions include Attachment 3.1-A, sections 1, 3, 5, 6.d, 17, 20, and 21.

Mental health and substance use disorder services

Mental health and substance use disorder services are covered without more restrictive financial requirements or treatment limitations than substantially all medical/surgical benefits in the same classification.

Behavioral health and substance use disorder services: Mental/behavioral health outpatient and inpatient services and substance use disorder outpatient and inpatient services are covered.None stated

The document states that applicable limits may be exceeded based on medical necessity for outpatient services. Substance use disorder services were revised within TN-21-0014, effective 07/01/21.

Prescription drugs

Prescription drug coverage is at least the greater of one drug in each USP category and class or the same number of drugs in each category and class as the base benchmark.

Prescription drugs: The prescription drug benefit must be the same as the approved Medicaid State Plan for prescribed drugs and must meet the stated USP or benchmark drug-count standard.At least one drug in each USP category and class or the same number as the base benchmark

The plan includes limits on days supply, number of prescriptions, and brand drugs, plus a preferred drug list. No authorization is required under this section. Prescription drug providers must be state licensed.

Rehabilitative and habilitative services and devices

Rehabilitative and habilitative services and devices are covered subject to service-specific limits and site restrictions.

Rehabilitation and habilitation: Outpatient rehabilitation and habilitation services are covered at 15 visits per year for each OT, PT, and ST. Habilitation services are provided only in outpatient hospitals. Home health, prosthetic, and orthotic services are covered subject to their authorization requirements.15 visits/year for each OT, PT, and ST; skilled nursing/inpatient rehabilitation hospital: 90 days per individual per SFY

Authorization is required in excess of the skilled nursing/inpatient rehabilitation limit; limits may be exceeded based on medical necessity. Home health services require prior authorization and must be provided by home health agencies. Prosthetic and orthotic devices require prior authorization. Some durable medical equipment items may also require prior authorization.

Laboratory services

Laboratory and diagnostic services are covered subject to prior authorization or other authorization rules.

Laboratory and imaging services: Imaging, laboratory outpatient and professional services, and X-rays and diagnostic imaging are covered.None stated

Prior authorization is required for CT scans, PET scans, and MRIs. Other authorization requirements apply to laboratory and X-ray/diagnostic imaging services.

Preventive, wellness, and pediatric services

Preventive, wellness, chronic disease management, and pediatric services are covered under the State Plan.

Preventive and pediatric services: Preventive care, screening, immunization, diabetes education, nutritional services, and Medicaid State Plan EPSDT benefits are covered.Diabetes education: 10 hours in the first year and 2 hours in each subsequent year; nutritional services: 6 hours/year

Prior authorization is required for diabetes education. Authorization is required in excess of the nutritional services limit, and limits may be exceeded based on medical necessity. EPSDT benefits are provided under the applicable State Plan provisions.

Adult dental benefits not included

The following adult dental benchmark benefits are not included in the Alternative Benefit Plan.

Adult dental exclusions: Basic dental care, adult orthodontia, routine adult dental care, and major adult dental care are not included because they are not mandatory benefits.

Additional benefit limitations and authorization

The following benefits are covered with stated limitations and authorization requirements.

Bariatric surgery is provided with prior authorization and is not covered for treatment of obesity alone.

The applicable State Plan provisions include Attachment 3.1-A, sections 1 and 5.

Podiatric services are provided with a limit of four office visits per month; authorization is required in excess of the limitation.4 office visits/month

The applicable provision is State Plan Attachment 3.1-A, section 6.a.

Eye care is provided only to treat a medical or surgical condition, with a limit of four office visits per month; authorization is required in excess of the limitation.4 office visits/month

The applicable provision is State Plan Attachment 3.1-A, section 6.b.

Meals and lodging:

Dental service authorization

The following covered dental services require prior authorization.

Dental services: Prior authorization is required for diagnostic dental, preventive dental, restorative dental, non-surgical periodontal therapy, and removable prosthetics dental services.

Each benefit references State Plan Attachment 3.1-A, section 10. These benefits were revised within TN-21-0014, effective 07/01/21.

Reconstructive surgery is covered only for non-cosmetic purposes. Breast reconstruction, implantation, or removal is covered only when it is the direct result of a medically necessary mastectomy.

Hospice services are not included as a separate base benchmark benefit. They are substituted with 1945 health home services covered under Oklahoma Medicaid State Plan Attachment 3.1-H.

Private duty nursing is not provided as a separate base benchmark benefit. It is substituted with skilled nursing under the home health services benefit, covered under State Plan Attachment 3.1-A, section 7.

Several base benchmark services are identified as substitutions or duplications because equivalent services are covered under Oklahoma Medicaid benefits. These include ambulatory, emergency, hospital, maternity, behavioral health, rehabilitation and habilitation, pediatric, laboratory, imaging, transplant-related, and other services under the applicable State Plan provisions.

The Alternative Benefit Plan does not include basic dental care for adults, adult orthodontia, routine adult dental care, or major adult dental care. These benchmark benefits are excluded because they are not mandatory benefits.

Bariatric surgery is not covered when it is provided for the treatment of obesity alone. Prior authorization is required for bariatric surgery when otherwise within the covered benefit scope.

Treatment of obesity alone is outside the covered scope for bariatric surgery.

Service Limits

Podiatric services

BenefitPodiatric services

Amount limit4 office visits/month

AuthorizationAuthorization required in excess of limitation

Provider qualificationsMedicaid State Plan

ReferenceApproved State Plan, Attachment 3.1-A, section 6.a.

Eye care for a medical or surgical condition

BenefitEye care to treat a medical or surgical condition

Authorization and Billing Requirements

Prior Authorization

Required Transplant Authorization

Obtain prior authorization for all organ transplantation services except kidney and cornea transplantation.

All transplantation services other than kidney and cornea transplantation require prior authorization.

Prior Authorization

Home Health Prior Authorization

Obtain prior authorization before providing home health services. Services must be delivered by a qualified home health agency.

Provider restriction: home health must be provided by home health agencies.

Unsupported block type: prior_auth

Prior Authorization

Advanced Imaging Prior Authorization

Alternative Benefit Plan Benchmark

The Oklahoma Alternative Benefit Plan uses the Blue Cross Blue Shield of Oklahoma Blue Options Gold 002 plan as its base benchmark and incorporates applicable Medicaid State Plan provisions. Covered services are organized across the essential health benefit categories and are subject to the benefit limits, authorization requirements, provider qualifications, and scope restrictions described in the applicable State Plan attachments.

Policy Summary

PayerOklahoma Health Care Authority

PolicyAlternative Benefit Plan

Policy CodePolicy N/A

Change TypeModified

Effective DateJuly 1, 2021

Next Review DateN/A

Key ActionObtain prior authorization for imaging, including CT scans, PET scans, and MRIs.

SourceLink

On This Page

Payment for lodging and meals assistance is provided only when medically necessary in connection with transportation to and from SoonerCare compensable services, for an eligible member and an approved medical escort if needed; prior authorization is required.

The applicable provision is State Plan Attachment 4.19-B, transportation, section C.

Amount limit4 office visits/month

AuthorizationAuthorization required in excess of limitation

Scope limitServices are to treat a medical or surgical condition only.

Provider qualificationsMedicaid State Plan

ReferenceApproved State Plan, Attachment 3.1-A, section 6.b.

Obtain prior authorization for advanced imaging services, including CT, PET, and MRI.

Affected services: Imaging (CT/PET scans, MRIs).
Reference approved State Plan, Attachment 3.1-A, sections 2.a. and 3.

Prior Authorization

Diabetes Education Authorization

Obtain prior authorization for diabetes education services. Services are limited to 10 hours in the first year and 2 hours in subsequent years unless the amount limit is exceeded based on medical necessity.

Amount limit: 10 hours in the first year; 2 hours in each subsequent year.
Amount limits may be exceeded based on medical necessity.

Prior Authorization

Bariatric Surgery Authorization and Coverage Limit

Obtain prior authorization for bariatric surgery. Bariatric surgery is not covered when obesity is the only indication.

Coverage is not available for treatment of obesity alone.
Reference approved State Plan, Attachment 3.1-A, sections 1 and 5.

Prior Authorization

Meals and Lodging Authorization

Obtain prior authorization for meals and lodging assistance. Payment is limited to medically necessary assistance connected with transportation to and from SoonerCare compensable services.

Assistance is limited to an eligible member and an approved medical escort, when needed.
Reference approved State Plan, Attachment 4.19-B, transportation, section C.

Prior Authorization

Dental Services Prior Authorization

Obtain prior authorization for specified dental services, including diagnostic, preventive, restorative, periodontal, and removable prosthetics dental services.

Affected services include diagnostic dental, preventive dental, restorative dental, non-surgical periodontal therapy, and removable prosthetics dental.
Reference approved State Plan, Attachment 3.1-A, section 10.

Note

Use Applicable State Plan Benefit Provisions

Use the applicable Oklahoma Medicaid State Plan attachments to determine benefit coverage, limits, provider qualifications, and service requirements.

Apply the relevant approved State Plan provisions, including Attachment 3.1-A sections 1, 2.a., 3, 5, 6.a., 6.b., 6.d., 7, 10, 12.c., 13.d.1., 13.d.5., 17, 20, 21, 24.a., 24.f., and 29, as applicable.
Also apply Attachment 3.1-D, Attachment 3.1-H, and Attachment 4.19-B when applicable.

Denial Risk

Exceeding Benefit Limits

When a service exceeds a stated amount or visit limit, obtain authorization when required and document medical necessity. Amount limits may be exceeded based on medical necessity where the applicable benefit provision allows it.

Examples include office visits, allergy testing, inpatient services, skilled nursing or inpatient rehabilitation, nutritional services, podiatric services, and medical or surgical eye-care visits.
Do not assume that exceeding a limit is covered without the required authorization or medical-necessity support.

Denial Risk

Cosmetic or Unsupported Reconstructive Surgery

Reconstructive surgery is limited to non-cosmetic indications. Breast reconstruction, implantation, or removal is covered only when directly resulting from a medically necessary mastectomy.

Cosmetic or unsupported reconstructive surgery is not covered.
Reference approved State Plan, Attachment 3.1-A, section 1.

Unsupported block type: denial_risk

Prior Authorization

Podiatric Visit Limit

Podiatric services are limited to four office visits per month. Obtain authorization for services above the limit.

Authorization is required in excess of the monthly limit.
Reference approved State Plan, Attachment 3.1-A, section 6.a.

Prior Authorization

Medical or Surgical Eye-Care Limits

Medical or surgical eye-care services are limited to treatment of a medical or surgical condition and four office visits per month. Obtain authorization for services above the limit.

Coverage is limited to treatment of a medical or surgical condition.
Authorization is required in excess of four office visits per month.
Reference approved State Plan, Attachment 3.1-A, section 6.b.