Title XIX State Plan

The State Plan is the officially recognized statement describing the nature and scope of any state’s Medicaid program.  As required under Section 1902 of the Social Security Act (the Act) the State Plan is developed by the state and approved by DHHS/CMS. Without a State Plan, OHCA would not be eligible for federal funding for providing SoonerCare services.  Essentially, the State Plan is our state’s agreement that it will conform to the requirements of the Act and the official issuances of DHHS/CMS. 

The State Plan includes the many provisions required by the Act, such as:

  •  Methods of Administration;
  •  Eligibility;
  •  Services Covered;
  •  Quality Control; and
  •  Fiscal Reimbursements.


Table of Contents

List of Attachments

1.0 – Single State Agency Organization 

                1.1 - Designation and Authority

1.2 - Organization for Administration

1.3 – Statewide Operation

1.4 State Medical Care Advisory Committee

1.5 Pediatric Immunization Program

Medicaid Eligibility

    S10 - MAGI Based Income Methodologies  

    S14 - AFDC Income Standards  

    S21 - Hospital Presumptive Eligibility  

    S25 - Eligibility Groups - Mandatory Coverage Parents and Other Caretaker Relatives  

    S28 - Eligibility Groups - Mandatory Coverage Pregnant Women  

    S30 - Eligibility Groups - Mandatory Coverage Infants and Children Under  Age 19  

    S32 - Mandatory Coverage Adult Group  

    S33 - Eligibility Groups - Mandatory Coverage Former Foster Care Children  

    S50 - Eligibility Groups - Options for Coverage Individuals Above 133% FPL

    S51 - Eligibility Groups - Options for Coverage Optional Coverage of Parents and Other Caretaker Relatives  

    S52 - Eligibility Groups - Options for Coverage Reasonable Classification of Individuals Under Age 21  

    S53 - Eligibility Groups - Options for Coverage Children with Non IV-E Adoption Assistance  

    S54 - Eligibility Groups - Options for Coverage Optional Targeted Low Income Children  

    S55 - Eligibility Groups - Options for Coverage Individuals with Tuberculosis  

    S57 - Eligibility Groups - Options for Coverage Independent Foster Care Adolescents  

    S59 - Eligibility Groups - Options for Coverage Individuals Eligible for Family Planning Services

    S88 -Non-Financial Eligibility State Residency  

    S89 - Non-Financial Eligibility Citizenship and Non-Citizen Eligibility  

    S94 - General Eligibility Requirements Eligibility Process


2.0 Coverage and Eligibility

                 2.1 Application, Determination of Eligibility and Furnishing Medicaid

                 2.2 Coverage and Conditions of Eligibility

                 2.3 Residence

                 2.4 Blindness

                 2.5 Disability

                 2.6 Financial Eligibility

                 2.7 Medicaid Furnished Out of State

3.0 Services: General Provisions

3.1 Amount, Duration, and Scope of Services

                 3.2 Coordination of Medicaid with Medicare Part B

                 3.3 Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases

                 3.4 Special Requirements Applicable to Sterilization Procedures

                 3.5 Medicaid for Medicare Cost Sharing for Qualified Medicare Beneficiaries

 3.6 Ambulatory Prenatal Care for Pregnant Women during Presumptive Eligibility Period


4.0 General Program Administration  

                4.1 Methods of Administration

                4.2 Hearings for Applicants and Recipients

                4.3 Safeguarding Information on Applicants and Recipients

                4.4 Medicaid Quality Control

                4.5 Medicaid Agency Fraud Detection and Investigation Program

                4.6 Reports

                4.7 Maintenance of Reports

                4.8 Availability of Agency Program Manuals

                4.9 Reporting Provider Payments to the Internal Revenue Service

                4.10 Free Choice of Providers

4.11 Standards for Institutions

                4.12 Consultation to Medical Facilities

                4.13 Required Provider Agreement

                4.14 Utilization/Quality Control

4.15 Inspections of Care in Skilled Nursing and Intermediate Care Facilities and Institutions for Mental Diseases

4.16 Relations with State Health and Vocational Rehabilitation Agencies and Title V Grantees

4.17 Liens and Recoveries – Long Term Care Insurance Partnership

                 4.18 Cost Sharing and Similar Charges

                4.19 Payment for Services

                4.20 Direct Payments to Certain Recipients for Physicians; or Dentists’ Services

                4.21 Prohibition Against Reassignment of Provider Claims

4.22 Third Party Liability

                4.23 Use of Contracts

4.24 Standards for Payments for Nursing Facility and Intermediate Care Facility for the Mentally Retarded Services

4.25 Program for Licensing Administrators of Nursing Homes

4.26 Drug Utilization Review Program

4.27 Disclosure of Survey Information and Provider or Contractor Evaluation

4.28 Appeals Process for Skilled Nursing and Intermediate Care Facilities

4.29 Conflict of Interest Provisions

4.30 Exclusion of Providers and Suspension of Practitioners Convicted and Other Individuals

                4.31 Disclosure of Information by Providers and Fiscal Agents

                4.32 Income and Eligibility Verification System

                4.33 Medicaid Eligibility Cards for Homeless Individuals

                4.34 Systematic Alien Verification for Entitlements

4.35 Remedies for Skilled Nursing and Intermediate Care Facilities that Do Not Meet Requirements of Participation

                4.36 Required Coordination Between the Medicaid and WIC Programs

                4.38 Nurse Aide Training and Competency Evaluation for Nursing Facilities

                4.39 Pre-admission Screening and Annual Resident Review in Nursing Facilities

                 4.43 Cooperation with Medicaid Integrity Program Efforts


  5.0 Personnel Administration

                5.1Standards of Personnel Administration

5.3Training Programs; Subprofessional and Volunteer Programs


6.0 Financial Administration

                 6.1 Fiscal Policies and Accountability

                 6.2 Cost Allocation

                 6.3 State Financial Participation


7.0 General Provisions

                 7.1 Plan Amendments

                 7.2 Nondiscrimination

                 7.3 Maintenance of AFDS Effort

                 7.4 State Governor's Review