OHCA Policies and Rules

Search Entire Policy
OHCA Policies and Rules Main Page

Part 5      DETERMINATION OF ELIGIBILITY FOR MEDICAL SERVICES

317:35-7-35.General eligibility consideration; categorically related family members [REVOKED]

[Revoked 07-01-13]

317:35-7-36.Financial eligibility of individuals categorically related to ABD
[Revised 10-01-05]
In determining financial eligibility for Medical Services for an individual related to ABD, the income and resources of the individual and spouse (if any) are considered. However, consideration is not given to the income and resources of a spouse included in a TANF case. Income of an ineligible spouse may be deemed to the minor dependent child as explained in OAC 317:35-7-38(1)(D). The income and resources of a minor dependent child are not considered in determining financial eligibility for the individual related to ABD. The minor dependent child is defined as any biological or adopted child under 18 years of age and residing in the home.
(1) If an individual and spouse cease to live together because of institutionalization or any other reason, income and resources are considered available to each other through the month in which they are separated. Mutual consideration ceases with the month after the month in which the separation occurs. Any amounts which are actually contributed to the eligible individual after the mutual consideration has ended are considered.
(2) If the individual related to Aid to the Blind or Aid to the Disabled is a minor child living in the home of parent(s) or spouse of a parent, the parent'(s) or spouses' income and resources are deemed to the child.
(A) Income is not deemed if the parent or spouse is included in a TANF case or determined categorically needy for Medicaid benefits only. A minor is defined as a child under 18 years and residing in the home. At the point that the minor child no longer resides in the home of the parent(s) or spouse of the parent, the deeming of income and resources ceases with the month after the month of separation. No longer residing in the home includes not only residing in the home of another, but also confinement in a medical facility if the confinement lasts, or is expected to last, 30 days. Any amounts which are actually contributed to the minor child after deeming ends are considered.
(B) For TEFRA children, the income and resources of the parent(s) are not considered.
(3) Premature infants (i.e., 37 weeks or less) whose birth weight is less than 1200 grams (approximately 2 pounds 10 ounces) will be considered disabled by SSA even if no other medical impairment(s) exist. In this event, the parent's income and resources are not deemed to the child until the month following the month in which the child leaves the hospital and begins living with his/her parents. While an infant born below this birth weight is considered disabled under SSI disability provisions, SSI cash payments are only effective the month the parent or legal guardian files an SSI application. If the SSI effective date does not go back to the month of birth, it will not be necessary to request a decision from the Level of Care Evaluation Unit at OHCA in order to consider the infant disabled effective the date of birth.

317:35-7-37.Financial eligibility of individuals categorically related to AFDC, or pregnancy-related services [REVOKED]

[Revoked 07-01-13]

317:35-7-38.Financial eligibility of categorically needy individuals related to ABD
[Revised 7-11-05]
(a) Income and resources below State Supplemental Payment (SSP) standard. Individuals whose income and resources meet SSP requirements on OKDHS Appendix C-1, Schedules VIII. A. and D., are considered categorically needy.
(1) Categorical Relationship. For an individual categorically related to ABD to be categorically needy at the SSP standard, the countable income must be less than the standards on OKDHS Appendix C-1, Schedule VIII. A. and the equity in capital resources cannot exceed the maximum allowable resources on OKDHS Appendix C-1, Schedule VIII. D. for the following groups:
(A) An eligible individual. An eligible individual is a single individual who is aged, blind or disabled and has total countable income less than the "Categorically Needy Standard for an Eligible Individual";
(B) An eligible individual and essential spouse. An essential spouse is defined as having been continuously included in the case since prior to 1974. The total countable income of both must be less than the "Categorically Needy Standard for Eligible Individual with Essential or Ineligible Spouse";
(C) An eligible individual and ineligible spouse. An ineligible spouse does not meet the definition of aged, blind or disabled nor the requirement as "essential". The total countable income of the eligible individual must be less than the "Categorically Needy Standard for Eligible Individual", and the total countable income of both must be less than the "Categorically Needy Standard for Eligible Individual with Essential or Ineligible Spouse";
(D) An eligible individual with a spouse ineligible for ABD and dependent children.
(i) If the spouse and dependent children are included in a TANF diversion payment or ongoing TANF benefits, their income is not deemed to the ABD eligible individual.
(ii) If the spouse's needs are not included in the TANF case for the children, the portion of the spouse's income that is considered in determining the grant for the children is not considered in the SSP case;
(E) An eligible couple. An eligible couple means a husband and wife who are both either aged, blind or disabled and have total countable income less than the "Categorically Needy Standard for Eligible Couple".
(2) Verification. Verification of receipt of SSI establishes financial eligibility with these exceptions:
(A) Countable income including SSI cannot be equal to or exceed the appropriate Categorically Needy Standards on OKDHS Appendix C-1, Schedule VIII. A.
(B) The individual must meet the OHCA's requirements on irrevocable burial funds.
(3) Related to ABD. Individuals who meet the definition of categorically needy with income below the SSP standard and categorically related to ABD are:
(A) Individuals in an active ABD case.
(B) Individuals categorically related to ABD whose countable income and resources are within current SSP standards for eligibility but who do not choose to receive financial assistance.
(C) Individuals in ABD cases who are eligible for Medicaid due to the disregard of Social Security cost of living increases (COLA) under the Pickle Amendment. An individual is eligible under the Pickle Amendment if the following conditions are met:
(i) is currently receiving OASDI;
(ii) has been eligible for and simultaneously received both OASDI and SSP for at least one month since April, 1977;
(iii) lost eligibility for SSP since April, 1977; and
(iv) would be eligible for SSP if OASDI COLA increases received since the closure of SSP case were deducted from countable income.
(D) Spouses "grandfathered in" as essential persons to ABD recipients when the ABD case load was converted to SSI on January 1, 1974, so long as they continue as an essential person to an eligible ABD recipient converted to SSI (even though there is a change in category within ABD).
(E) Individuals in ABD cases who continue to be eligible for Medicaid because the Social Security Administration has determined that they still qualify as "disabled" (by classifying as 1619(b) of the Social Security Act) even though they become employed and lose eligibility for SSI benefits due to the earned income. To retain Medicaid eligibility, the individual must have received Medicaid for the month prior to the determination by SSA. Income and resources excluded by SSA are also disregarded by OKDHS for these individuals. The county is responsible for the periodic redetermination of eligibility. The individual who meets all other factors of eligibility without consideration of income, resources or disability remains eligible until the SSI status changes.
(F) Individuals in blind or disabled cases who have become ineligible for SSP because of becoming entitled to or receiving an increase in OASDI (Title II) Widow's/Widower's benefits. They may continue to qualify for Medicaid as categorically needy until age 65 or upon entitlement to Medicare Part A benefits if they also meet the following criteria:
(i) Are at least 60 but not yet 65;
(ii) Are not entitled to Medicare;
(iii) Received SSI prior to age 60; and
(iv) Meet all other factors of eligibility.
(G) Individuals in blind or disabled cases who become ineligible for SSP due to entitlement of OASDI (Title II) Disabled Widow's/Widower's and Disabled Surviving Divorced Spouse's benefits. This group's eligibility as categorically needy terminates at age 65 or upon entitlement to Medicare Part A benefits. Each month the individual received SSI/SSP will count toward meeting the 24-month Medicare waiting period. This may greatly reduce or even eliminate the normal waiting period of Medicare. Care must be taken to determine if and when these individuals become eligible for Medicare Part A benefits. This group's Medicaid eligibility may continue if they also meet the following criteria:
(i) Received SSP for the month prior to the month they began receiving the OASDI benefits;
(ii) Not entitled to Medicare Part A; and
(iii) Meet all other factors of Medicaid eligibility.
(H) A, B or D recipients (who are at least 18 years of age) who have become ineligible for an SSP due to the receipt of or increase in OASDI child's benefits [Disabled Adult Child (DAC)] which are based on their own disability.
(I) A, B or D recipients who lost their SSP eligibility due to a reduction in the maximum SSP payment. (OKDHS Appendix C-1, Schedule VIII.) These individuals remain eligible for Medicaid benefits.
(4) SSP eligible. If a categorically needy applicant for Medicaid is also eligible for a State Supplemental Payment, the certification includes both Medicaid and the state payment.
(5) Potentially Qualified Medicare Beneficiary Plus eligible. The individual determined as categorically needy is also potentially eligible as a Qualified Medicare Beneficiary Plus (QMBP) (refer to subsection (b) of this Section). A determination is done to decide if income and resources are within standards on OKDHS Appendix C-1, Schedule VI., in which the income standards are based on 100% of the Federal Poverty Level. If the individual exercises the option of choosing QMBP coverage only, he/she is not certified to receive the State Supplemental Payment.
(b) Income and resources at or above the SSP standard. Individuals whose income and resources are at or above the SSP standard but less than the standards on OKDHS Appendix C-1, Schedule VI. are considered categorically needy.

317:35-7-39.Financial eligibility of medically needy individuals [REVOKED]
[Revoked 7-1-03]

317:35-7-40.Eligibility as Qualified Medicare Beneficiary Plus
[Revised 09-14-18]

An individual determined to be categorically related to aged, blind or disabled is eligible for Medical Services as a Qualified Medicare Beneficiary Plus (QMBP) if he/she meets the conditions of eligibility shown in paragraphs (1)-(3) of this subsection. For persons age 65 and older in mental health hospitals, refer to Oklahoma Administrative Code 317:35-9-7.

(1) The individual's/couple's income and resources do not exceed the standards as shown on DHS Appendix C-1, Schedule VI, of which the income standard is based on 100 percent of the Federal Poverty Level.

(2) Countable income and resources are determined using the same rules followed in determining eligibility for individuals categorically related to Aged, Blind or Disabled, except that a $20 general income disregard is applied to either earned or unearned income, but not both. For couples, only one $20 general income disregard is given.

(3) The individual meets all other eligibility conditions for SoonerCare.

 
317:35-7-41.Eligibility as Qualified Disabled and Working Individual
[Revised 07-01-07]
(a) An individual determined to be categorically related to Aid to the Blind or Disabled is eligible for Medicaid as a Qualified Disabled and Working Individual (QDWI) if the following eligibility conditions are met.
(1) Social Security disability benefits were terminated solely due to excess earnings.
(2) Countable income and resources do not exceed the standards as shown on DHS Appendix C-1, Schedule V, in which the income standards are based on 200% of the Federal Poverty Level.
(3) Medicaid eligibility cannot be established under QMB or categorically needy programs.
(4) Individual is enrolled in Medicare Part A.
(b) Individuals applying for QDWI must also meet the general eligibility requirements for social security number, residence, citizenship, and assignment of rights. Refer to OAC 317:35-5-25 regarding citizenship/alien status and identity verification requirements.
(c) Countable income and resources are determined using the same rules followed in determining eligibility for individuals categorically related to Aid to the Aged, Blind or Disabled, with the following exception: The $20 general income disregard is applied to either earned or unearned income, but not both.
(d) Coverage for a Qualified Disabled and Working Individual is restricted to payment of the Medicare Part A premiums. Medical cards are not issued.

317:35-7-42.Presumptive eligibility for pregnant women [REVOKED]
[Revoked 1-01-99]

317:35-7-43.Eligibility as Specified Low-Income Medicare Beneficiaries
[Revised 1-01-99]
An individual determined to be categorically related as aged, blind or disabled is eligible as a Specified Low-Income Medicare Beneficiary (SLMB) if he/she meets the conditions of eligibility in paragraphs (1) and (2) of this Section. For persons age 65 and older in mental health hospitals, refer to OAC 317:35-9-7.
(1) The individual is enrolled for Medicare hospital insurance benefits under Part A, which includes an individual entitled to hospital insurance benefits by reason of voluntary enrollment in the premium-paying Part A program.
(2) The individual's income and resources do not exceed the standard as shown on DHS Appendix C-1, Schedule VII, of which the income standard is based on 120% of the Federal Poverty Level. State Supplemental Payments are not considered when determining the countable income. For an individual whose spouse is not eligible for Medicare, total countable income of the eligible individual must be equal to or less than the SLMB standards for an individual and the income of both must be equal to or less than the SLMB standards for a couple. For a couple who are both eligible for Medicare, total countable income must be equal to or less than the SLMB standards for a couple. Countable income and resources are determined using the same rules followed in determining eligibility for individuals categorically related to Aid to the Aged, Blind or Disabled, except that a $20 general income disregard is also applied to either earned or unearned income, but not both. For couples, only one $20 general income disregard is given.

317:35-7-44.Eligibility for TB related services
[Revised 1-01-99]
(a) An individual determined to be categorically related to disability because of TB is eligible for limited Medicaid benefits if he/she meets the conditions of eligibility shown in paragraphs (1)-(4) of this subsection.
(1) Must have verification of active TB infection from a medical practitioner;
(2) Countable income (earned and unearned) must be less than the categorically needy standards shown on DHS Appendix C-1, Schedule XIII. The income standard is based on the break-even point which is described in the Social Security Procedure/Operations Manual (POMS-SI 00810.350).
(3) Equity in capital resources cannot exceed the maximum allowable resources on DHS Appendix C-1, Schedule XIII., which is the allowable SSI resource standard for an individual.
(4) The individual meets all other eligibility conditions for Medicaid.
(b) Coverage is restricted to payment of TB related services with unlimited TB related drugs. Separate eligibility determinations are made for regular Medicaid and TB related services.
(c) Medical identification cards will be issued to all individuals determined eligible for TB related services.
(d) In cases where both members of a married couple or more than one member of a family are TB infected, each applicant shall be considered as a single individual and be subject to independent income and resource standards.

317:35-7-45.Eligibility for catastrophic illness [REVOKED]
[Revoked 7-1-03]

317:35-7-46.Eligibility as Qualifying Individuals
[Revised 6-25-04]
An individual determined to be categorically related as aged, blind or disabled is eligible as a Qualifying Individual (QI) if he/she meets the conditions of eligibility in paragraphs (1), (2), and (3) of this Section.
(1) The individual is enrolled for Medicare hospital insurance benefits under Part A, which includes an individual entitled to hospital insurance benefits by reason of voluntary enrollment in the premium-paying Part A program.
(2) The individual's income and resources do not exceed the standard as shown on DHS Appendix C-1, Schedule VII.A for QI-1. The maximum income standard for the QI-1 program is an amount greater than 120% but less than 135% of the Federal Poverty Level. For an individual whose spouse is not eligible for Medicare, total countable income of the eligible individual must be equal to or less than the QI standards for an individual and the income of both must be equal to or less than the QI standards for a couple. For a couple who are both eligible for Medicare, total countable income must be equal to or less than the QI standards for a couple. Countable income and resources are determined using the same rules followed in determining eligibility for individuals categorically related to Aid to the Aged, Blind or Disabled, with the following exceptions:
(A) Payments from Champus for medical care or from VA for Aid and Attendance are not considered in determining income eligibility.
(B) A $20 general income disregard is also applied to either earned or unearned income, but not both. For couples, only one $20 general income disregard is given.
(3) A Qualifying Individual cannot be otherwise eligible for Medicaid. Therefore, unlike QMB and SLMB individuals who may be determined eligible for Medicaid benefits in addition to their QMB/SLMB benefits, a QI recipient cannot be receiving or eligible for any other type of Medicaid benefit.

317:35-7-48.Eligibility for the SoonerPlan Family Planning Program

[Revised 09-14-18]

(a) Non-pregnant women and men ages 19 and above are eligible to receive family planning services if they meet all of the conditions of eligibility in paragraphs (1), (2), (3), and (4) of this Subsection. This is regardless of pregnancy or paternity history and includes women who gain eligibility for SoonerCare family planning services due to a pregnancy, but whose eligibility ends 60 days postpartum.

(1) MAGI financial eligibility rules are used to determine eligibility for SoonerPlan.

(2) MAGI household composition rules are used to determine eligibility for SoonerPlan.

(3) SoonerPlan members with minor dependent children and a parent absent from the home are required to cooperate with the Oklahoma Department of Human Services, Child Support Services Division (OCSS) in the collection of child support payments.  Federal regulations provide a waiver of this requirement when cooperation is not in the best interest of the child.

(4) Individuals eligible for SoonerCare can choose to enroll only in the SoonerPlan Family Planning Program with the option of applying for SoonerCare at any time.

(5) Persons who have Medicare or creditable health insurance coverage are not precluded from applying for the SoonerPlan Family Planning program.

(b) All health insurance is listed on applicable systems in order for OHCA Third Party Liability Unit to verify insurance coverage. The OHCA is the payer of last resort.

(c) Income for the SoonerPlan Family Planning Program does not require verification, unless questionable. If the income is questionable the worker must verify the income.

(d) There is not an asset test for the SoonerPlan Family Planning Program.

 

 

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.