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Part 7      APPLICATION AND ELIGIBILITY DETERMINATION PROCEDURES

317:35-5-60.Application for SoonerCare; forms

[Issued 07-01-13]

(a) Application.  An application for Medical Services consists of the Medical Assistance Application.  The application form is signed by the individual, parent, spouse, guardian or someone else acting on the individual's behalf.  An individual does not have to have received a medical service nor expect to receive one to be certified for SoonerCare. Effective January 1, 2014, the application form is available as an online application, as a paper form, and is available to be completed by telephone with the assistance of the agency.

(1) An application may be made in a variety of locations, for example, a physician's office, a hospital or other medical facility or in the county OKDHS office.  An application may be made online by individuals who are pregnant, have children or are applying for family planning services only.  A face to face interview is not required.  Only SoonerCare applications for women who are pregnant, families with children and for family planning services are mailed to the OHCA Eligibility Unit.  Applications for other medical services may be mailed or faxed to the local county OKDHS office.  If faxed, it is not necessary to send the original application.  When an individual indicates a need for health benefits, the physician or facility may forward an application or 08MA005E to the OKDHS county office of the patient's residence for processing.  The physician or facility may forward an application or 08MA005E for individuals who are pregnant, have children or are applying for family planning services only to the OHCA Eligibility Unit for processing.  If the applicant is unable to sign the application, someone acting on his/her behalf may sign the application.  Effective October 1, 2013, an application for SoonerCare may also be submitted through the Health Insurance Exchange.

(2) OKDHS form 08MA005E, Notification of Needed Medical Services, is required only for preauthorization of medical services.  Although not required, the form may be submitted by the physician or facility as notification of a need for medical services.  The form also may be accepted as medical verification of pregnancy.

(3) Receipt of the SoonerCare Application form or OKDHS form 08MA005E constitutes an application for SoonerCare.

(4) If OKDHS form 08MA005E is received and an application cannot be completed, receipt of OKDHS form 08MA005E constitutes an application which must be registered and subsequently denied.  The applicant and provider are notified by computer-generated notice.

(5) If the applicant also wishes to apply for a State Supplemental Payment, either the applicant or his/her guardian must sign the Medical Assistance Application form.

(b) Date of application.  When an application is made online, the date of application is the date the application is submitted online. The date of application for a paper application is the date a signed application is received and stamped in by contracted agency partners or OHCA.  When a request for SoonerCare is made orally, and that request is followed within 20 days by a signed application, the documented date of the oral request is the date of application. When OKDHS form 08MA005E is received by OKDHS, or received by OHCA and forwarded to OKDHS, the earliest of the date stamps is considered the date of request and should be honored when followed within 20 days by a signed application for SoonerCare.

317:35-5-61.[RESERVED]
[Reserved 07-01-13]
317:35-5-62.[RESERVED]
[Reserved 07-01-13]
317:35-5-62.1.Electronic Notices
[Issued 09-01-15]

(a) The agency allows SoonerCare members the choice to receive SoonerCare notices and information through electronic formats.

(1) SoonerCare members who elect to receive electronic notices will have this election confirmed by regular mail.

(2) SoonerCare members will be able to change this election by regular mail, telephone, or through the SoonerCare application.

(b) The agency will ensure all notices it generates will be posted to the member's individual account within one business day.

(1) The agency will send an email or other electronic communication alerting SoonerCare members that a notice has been posted to their member account.

(2) The agency will not include the member's confidential information in the email or electronic communication alert.

(3) The agency will send a notice by mail within three business days of a failed email or electronic alert that was undeliverable to the member.

(4) At the member's request, all notices that are posted to the member's account may also be provided through mail.

(c) Electronic notices that are posted to the member's account which require the member to take certain action, submit additional documentation, or contain eligibility, appeal, or SoonerCare benefits information are considered the same as if the notice was sent by mail to the member.
317:35-5-63.Agency responsible for determination of eligibility

[Issued 07-01-13]

(a) Determination of eligibility by OHCA. OHCA is responsible for determining eligibility for the following eligibility groups:

(1) children

(2) newborns deemed eligible

(3) grandfathered CHIP children

(4) pregnant women

(5) pregnancy-related services under Title XXI

(6) parents and caretaker relatives

(7) former foster care children

(8) Oklahoma Cares Breast and Cervical Cancer program

(9) SoonerPlan Family Planning program.

(b) Determination of eligibility by OKDHS. OKDHS is responsible for determining eligibility for the following eligibility groups:

(1) TANF recipients

(2) recipients of adoption assistance or kinship guardianship assistance

(3) state custody

(4) Refugee Medical Assistance

(5) aged

(6) blind

(7) disabled

(8) Tuberculosis

(9) QMBP

(10) QDWI

(11) SLMB

(12) QI-1

(13) Long term care services

(14) alien emergency services.

(c) Determination of eligibility for programs offered through the Health Insurance Exchange. Effective October 1, 2013, OHCA assesses applicants who are found to be ineligible for SoonerCare for potential eligibility for affordable insurance programs offered through the Health Insurance Exchange. OHCA does not determine eligibility or ineligibility for those programs. OHCA facilitates the determination for those affordable insurance programs by forwarding applicants' electronic applications to the Health Insurance Exchange.

317:35-5-64.Cooperation in determination of eligibility

[Issued 07-01-13]

(a) If an applicant does not cooperate in determination of eligibility and/or the agency does not have sufficient information to determine or redetermine eligibility, the application is denied or benefits are terminated for that reason. The agency responsible for determining eligibility provides the applicant with notice of outstanding requirements that must be met before eligibility can be determined.

(b) If an applicant or member cannot be located to assist in determination or redetermination of eligibility, the application is denied or benefits are terminated. Notice is sent to the applicant or member's last known address.

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.