Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 1 - General Provisions › Section 317:35-1-2 - Definitions

Current through Vol. 41, No. 20, July 1, 2024
The following words and terms, when used in this Chapter,
				  have the following meaning, unless the context clearly indicates
				  otherwise:
"Acute Care Hospital"
means an institution that
				  meets the requirements defined in Section (§) 440.10 of Title 42 of the
				  Code of Federal Regulations (C.F.R.) and:
(A) Is maintained primarily for the care and treatment of
				  patients with disorders other than mental diseases;
(B) Is formally licensed or formally approved as a hospital
				  by an officially designated authority for state standard setting; and
(C) Meets the requirements for participation in Medicare as a
				  hospital.
"Adult"
means an individual twenty-one (21)
				  years of age or older, unless otherwise specified by statute, regulation,
				  and/or policy adopted by the Oklahoma Health Care Authority (OHCA). For
				  eligibility criteria policy for children and adults, please refer to Oklahoma
				  Administrative Code (OAC)
				  317:35-5-2.
"ADvantage Administration (AA)"
means the
				  Oklahoma Department of Human Services (OKDHS) which performs certain
				  administrative functions related to the ADvantage Waiver.
"Aged"
means an individual whose age is
				  established as sixty-five (65) years or older.
"Agency partner"
means an agency or organization
				  contracted with the OHCA that will assist those applying for services.
"Aid to Families with Dependent Children (AFDC)"
means the group of low- income families with children described in Section 1931
				  of the Social Security Act. The Personal Responsibility and Work Opportunity
				  Act of 1996 established the new eligibility group of low- income families with
				  children and linked eligibility income and resource standards and methodologies
				  and the requirement for deprivation for the new group to the State plan for
				  AFDC in effect on July 16, 1996. Oklahoma has elected to be less restrictive
				  for all SoonerCare members related to AFDC. Children covered under Section 1931
				  are related to the children's group, and adults covered under Section 1931 are
				  related to the parent and caretaker relative group. The Modified Adjusted Gross
				  Income (MAGI) methodology is used to determine eligibility for these groups.
"Alien"
is synonymous with the word "noncitizen"
				  and means an individual who does not have United States citizenship and is not
				  a United States national.
"Area nurse"
means a registered nurse in the
				  OKDHS Aging Services Division, designated according to geographic areas who
				  evaluates the Uniform Comprehensive Assessment Tool (UCAT) and determines
				  medical eligibility for Personal Care, ADvantage Waiver, and Nursing Facility
				  services. The area nurse also approves care plan and service plan
				  implementation for Personal Care services.
"Area nurse designee"
means a registered nurse
				  selected by the area nurse who evaluates the UCAT and determines medical
				  eligibility for Personal Care, ADvantage Waiver, and Nursing Facility services.
"Authority"
means the OHCA.
"Blind"
means an individual who has central
				  visual acuity of 20/200 or less in the better eye with the use of a correcting
				  lens.
"Board"
means the OHCA Board.
"Buy-in"
means the procedure whereby the OHCA
				  pays the member's Medicare premium.
(A)
"Part A Buy-in"
means the procedure whereby
				  the OHCA pays the Medicare Part A premium for individuals determined eligible
				  as Qualified Medicare Beneficiaries Plus (QMBP) who are enrolled in Part A and
				  are not eligible for premium free enrollment as explained under Medicare Part
				  A. This also includes individuals determined to be eligible as Qualified
				  Disabled and Working Individuals (QDWI).
(B)
"Part B Buy-in"
means the procedure whereby
				  the OHCA pays the Medicare Part B premium for categorically needy individuals
				  who are eligible for Part B Medicare. This includes individuals who receive
				  TANF or the State Supplemental Payment to the Aged, Blind or Disabled, and
				  those determined to be Qualified Medicare Beneficiary Plus (QMBP), Specified
				  Low Income Medicare Beneficiaries (SLMB) or Qualifying Individual-1 (QI-1).
				  Also included are individuals who continue to be categorically needy under the
				  PICKLE amendment and those who retain eligibility after becoming employed.
"Caretaker relative"
means a person other than
				  the biological or adoptive parent with whom the child resides who meets the
				  specified degree of relationship within the fifth degree of kinship.
"Case management"
means the activities performed
				  for members to assist them in accessing services, advocacy and problem solving
				  related to service delivery.
"Categorically needy"
means that income and,
				  when applicable, resources are within the standards for the category to which
				  the individual is related.
"Categorically related"
or
"related"
means the individual meets basic eligibility requirements for an eligibility
				  group.
"Certification period"
means the period of
				  eligibility extending from the effective date of certification to the date of
				  termination of eligibility or the date of the next periodic redetermination of
				  eligibility.
"Child"
means an individual under twenty-one
				  (21) years of age, unless otherwise specified by statute, regulation, and/or
				  policy adopted by the OHCA. For eligibility criteria policy for children and
				  adults, please refer to OAC
				  317:35-5-2.
"County"
means the Oklahoma OKDHS' office or
				  offices located in each county within the State.
"Custody"
means the custodial status, as
				  reported by OKDHS.
"Deductible/Coinsurance"
means the payment that
				  must be made by or on behalf of an individual eligible for Medicare before
				  Medicare payment is made. The coinsurance is that part of the allowable medical
				  expense not met by Medicare, which must be paid by or on behalf of an
				  individual after the deductible has been met.
(A) For Medicare Part A (Hospital Insurance), the deductible
				  relates to benefits for inpatient services while the patient is in a hospital
				  or nursing facility. After the deductible is met, Medicare pays the remainder
				  of the allowable cost.
(B) For Medicare Part B (Medical Insurance), the deductible
				  is an annual payment that must be made before Medicare payment for medical
				  services. After the deductible is met, Medicare pays eighty percent (80%) of
				  the allowable charge. The remaining twenty percent (20%) is the
				  coinsurance.
"Disabled"
means an individual who is unable to
				  engage in any substantial gainful activity by reason of any medically
				  determinable physical or mental impairment which can be expected to result in
				  death, or which has lasted (or can be expected to last) for a continuous period
				  of not less than twelve (12) months.
"Disabled child"
means for purposes of Medicaid
				  Recovery a child of any age who is blind, or permanently and totally disabled
				  according to standards set by the Social Security Administration.
"Estate"
means all real and personal property
				  and other assets included in the member's estate as defined in Title 58 of the
				  Oklahoma Statutes.
"Expansion adult"
means an individual defined by
				  42
				  Code of Federal Regulations (C.F.R.) §
										435.119 who is age nineteen (19) or older and
				  under sixty-five (65), at or below 133 percent of the federal poverty level
				  (FPL), and who are not related to the aged, blind, or disabled.
"Gatekeeping"
means the performance of a
				  comprehensive assessment by the OKDHS nurse utilizing the UCAT for the
				  determination of medical eligibility, care plan development, and the
				  determination of Level of Care for Personal Care, ADvantage Waiver and Nursing
				  Facility services.
"Ineligible Spouse"
means an individual who is
				  not eligible for Supplemental Security Income (SSI) but is the husband or wife
				  of someone who is receiving SSI.
"Lawfully present"
means a noncitizen in the
				  United States who is considered to be in lawful immigration status or class.
"Lawfully residing"
means the individual is
				  lawfully present in the United States and also meets Medicaid residency
				  requirements.
"Local office"
means the Oklahoma OKDHS' office
				  or offices located in each county within the State.
"LOCEU"
means the Oklahoma Health Care
				  Authority's Level of Care Evaluation Unit.
"MAGI eligibility group"
means an eligibility
				  group whose financial eligibility is determined through the Modified Adjusted
				  Gross Income (MAGI) methodology. The groups subject to MAGI are defined in 42
				  C.F.R. § 436.603 and listed in OAC
				  317:35-6-1.
"Modified Adjusted Gross Income (MAGI)"
means
				  the financial eligibility determination methodology established by the Patient
				  Protection and Affordable Care Act (PPACA) in 2009.
"Medicare"
means the federally funded health
				  insurance program also known as Title XVIII of the Social Security Act. It
				  consists of four (4) separate programs. Part A is Hospital Insurance, Part B is
				  Medical Insurance, Part C is Medicare Advantage Plans, and Part D is
				  Prescription Drug Coverage.
(A)
"Part A Medicare"
means Hospital Insurance
				  that covers services for inpatient services while the patient is in a hospital
				  or nursing facility. Premium free enrollment is provided for all persons
				  receiving Old Age, Survivors, and Disability Insurance (OASDI) or Railroad
				  Retirement income who are age sixty-five (65) or older and for those under age
				  sixty-five (65) who have been receiving disability benefits under these
				  programs for at least twenty-four (24) months.
(i) Persons with end- stage renal disease who require
				  dialysis treatment or a kidney transplant may also be covered.
(ii) Those who do not receive OASDI or Railroad Retirement
				  income must be age sixty-five (65) or over and pay a large premium for this
				  coverage. Under Authority rules, these individuals are not required to enroll
				  for Part A to be eligible for SoonerCare benefits as categorically needy. They
				  must, however, enroll for Medicare Part B. Individuals eligible as a QMBP or as
				  a QDWI under Medicaid are required to enroll for Medicare Part A. The Authority
				  will pay Part A premiums for QMBP individuals who do not qualify for premium
				  free Part A and for all QDWI's.
(B)
"Part B Medicare"
means Supplemental Medical
				  Insurance that covers physician and related medical services other than
				  inpatient or nursing facility care. Individuals eligible to enroll in Medicare
				  Part B are required to do so under OHCA policy. A monthly premium is required
				  to keep this coverage in effect.
"Minor child"
means a child under the age of
				  eighteen (18).
"Noncitizen"
is synonymous with the word "alien"
				  and means an individual who does not have United States citizenship and is not
				  a United States national.
"Nursing Care"
for the purpose of Medicaid
				  Recovery is care received in a nursing facility, an intermediate care facility
				  for individuals with intellectual disabilities (ICF/IIDs) or other medical
				  institution providing nursing and convalescent care, on a continuing basis, by
				  professional personnel who are responsible to the institution for professional
				  medical services.
"OCSS"
means the OKDHS' Oklahoma Child Support
				  Services (formerly Child Support Enforcement Division).
"OHCA"
means the Oklahoma Health Care Authority.
"OHCA Eligibility Unit"
means the group within
				  the OHCA that assists with the eligibility determination process.
"OKDHS"
means the Oklahoma Department of Human
				  Services which is also referenced in rules as Department of Human Services
				  (DHS) and Office of Human Services (OHS).
"OKDHS nurse"
means a registered nurse in the
				  OKDHS Aging Services Division who meets the certification requirements for UCAT
				  Assessor and case manager, and who conducts the uniform assessment of
				  individuals utilizing the UCAT for the purpose of medical eligibility
				  determination. The OKDHS nurse also develops care plans and service plans for
				  Personal Care services based on the UCAT.
"Qualified Disabled and Working Individual
				  (QDWI)"
means individuals who have lost their Title II OASDI benefits
				  due to excess earnings but have been allowed to retain Medicare coverage.
"Qualified Medicare Beneficiary Plus (QMBP)"
means certain aged, blind or disabled individuals who may or may not be
				  enrolled in Medicare Part A, meet the Medicaid QMBP income and resource
				  standards and meet all other Medicaid eligibility requirements.
"Qualifying Individual"
means certain aged,
				  blind or disabled individuals who are enrolled in Medicare Part A, meet the
				  Medicaid Qualifying Individual income and resource standards and meet all other
				  Medicaid eligibility requirements.
"Qualifying Individual-1"
means a Qualified
				  Individual who meets the Qualifying Individual-1 income and resource standards.
"Reasonably compatible"
means that there is no
				  significant discrepancy between information declared by a member or applicant
				  and other information available to the agency. More specific policies and
				  procedures for determining whether a declaration is reasonably compatible are
				  detailed in Oklahoma's Verification Plan.
"Recipient lock-in"
means when a member is
				  restricted to one primary physician and/or one pharmacy. It occurs when the
				  OHCA determines that a SoonerCare member has used multiple physicians and/or
				  pharmacies in an excessive manner over a twelve (12) month period.
"Scope"
means the covered medical services for
				  which payment is made to providers on behalf of eligible individuals. The OHCA
				  Provider Manual (OAC 317:30) contains information on covered medical services.
"Specified Low Income Medicare Beneficiaries
				  (SLMB)"
means individuals who, except for income, meet all of the
				  eligibility requirements for QMBP eligibility and are enrolled in Medicare Part
				  A.
"TEFRA"
means the Tax Equity and Fiscal
				  Responsibility Act of 1982 ( Public Law 97-248). TEFRA provides coverage to
				  certain disabled children living in the home who would qualify for SoonerCare
				  if residents of nursing facilities, Intermediate Care Facilities for
				  Individuals with Intellectual Disabilities (ICF/IIDs), or inpatient acute care
				  hospital stays are expected to last not less than sixty (60) days.
"Worker"
means the OHCA or OKDHS worker
				  responsible for assisting in eligibility determinations.
Added at 12 Ok Reg 753, eff 1-6-95 through 7-14-95
					 (emergency) ; Added at 12 Ok Reg 3133, eff 7-27-95 ; Amended at 13 Ok Reg 911,
					 eff 8-1-95 (emergency) ; Amended at 14 Ok Reg 56, eff 4-30-96 (emergency) ;
					 Amended at 13 Ok Reg 2537, eff 6-27-96 ; Amended at 14 Ok Reg 1802, eff 5-27-97
					 ; Amended at 15 Ok Reg 544, eff 12-1-97 (emergency) ; Amended at 15 Ok Reg
					 1554, eff 5-11-98 ; Amended at 15 Ok Reg 3679, eff 5-18-98 (emergency) ;
					 Amended at 16 Ok Reg 60, eff 9-11-98 (emergency) ; Amended at 16 Ok Reg 1438,
					 eff 5-27-99 ; Amended at 17 Ok Reg 2410, eff 6-26-00 ; Amended at 18 Ok Reg
					 114, eff 11-1-00 (emergency) ; Amended at 18 Ok Reg 1139, eff 5-11-01 ; Amended
					 at 19 Ok Reg 136, eff 9-1-01 (emergency) ; Amended at 19 Ok Reg 2149, eff
					 6-27-02 ; Amended at 20 Ok Reg 2775, eff 7-1-03 (emergency) ; Amended at 21 Ok
					 Reg 2234, eff 6-25-04 ; Amended at 22 Ok Reg 2494, eff 7-11-05 ; Amended at 23
					 Ok Reg 268, eff 9-1-05 (emergency) ; Amended at 23 Ok Reg 1378, eff 5-25-06 ;
					 Amended at 26 Ok Reg 758, eff 4-1-09 (emergency) ; Amended at 27 Ok Reg 711,
					 eff 2-4-10 (emergency) ; Amended at 27 Ok Reg 1471, eff 6-11-10 ; Amended at 30
					 Ok Reg 1209, eff 7-1-13