reglab/statecodes huggingface dataset:
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 5 - Eligibility and Countable Income › Part 5 - COUNTABLE INCOME AND RESOURCES › Section 317:35-5-41.10 - Changes in capital resources

Current through Vol. 41, No. 20, July 1, 2024
(a)
Capital resources of an applicant or member currently receiving
				  assistance.
If the resource(s) of an applicant is in a form which is not
				  available for immediate use, such as real estate, mineral rights, or one of
				  many other forms, and the applicant is trying to make the resource available,
				  the applicant may be certified and given a reasonable amount of time to make
				  this available. If a member who is currently receiving medical assistance
				  acquires resources which increase his/her available resources at an amount
				  above the maximum resource standard, he/she is given a reasonable amount of
				  time to make the resources available. A reasonable amount of time would
				  normally not exceed 90 days. The member is notified in writing that a period of
				  time not to exceed 90 days will be given to make the resource available. Any
				  extension beyond the initial 90 day period is justified only after interviewing
				  the member, determining that a good faith effort is still being made and that
				  failure to make the resource available is due to circumstances beyond the
				  control of the member.
(b)
Money borrowed on member's resources.
Money borrowed on any of the
				  member's resources, except the home, merely changes his/her resource from one
				  form to another. Money borrowed on the home is evaluated in relation to the
				  maximum reserve standard.
(c)
Transfer of resources.
Rules on transfer or disposal of capital
				  resources are not applicable unless the individual enters a nursing home or
				  receives Home and Community Based Waiver Services, HCBWS/MR or ADvantage waiver
				  services. [See OAC 317:35-9, OAC 317:35-17, and OAC 317:35-19]
Added at 25 Ok Reg
					 130, eff 8-1-07 (emergency); Added at 25 Ok Reg 1257, eff 5-25-08; Amended at
					 26 Ok Reg 2132, eff 6-25-09
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 5 - Eligibility and Countable Income › Part 5 - COUNTABLE INCOME AND RESOURCES › Section 317:35-5-41.11 - Maximum resources

Current through Vol. 41, No. 20, July 1, 2024
Maximum resources is a term used to designate the largest
					 amount which a member can have in one or more nonexempt resources, and still be
					 considered to be in need. A member's resources may be held in any form or
					 combination of forms. If the resources of the applicant or member exceed the
					 maximums listed on OKDHS Appendix C-1, he/she is not eligible.
(1) For each minor blind or disabled child up
				  to the age of 18 living with parent(s) whose needs are not included in a TANF
				  grant, or receiving SSI and/or SSP, the resource limit is the same as the
				  individual limit as shown on OKDHS Appendix C-1. If the parent's resources
				  exceed the maximum amount, the excess is deemed available to the child
				  (resources of an ineligible child are not deemed to an eligible child). If
				  there is more than one eligible child, the amount is prorated.
(2) If the minor blind or disabled child:
(A) is residing in a nursing facility, or a
				  medical facility if the confinement lasts or is expected to last for 30 days,
				  the parent(s)' resources are not deemed to the child; or
(B) under age 19 is eligible for TEFRA, the
				  parent's(s') resources are not deemed to the child.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 5 - Eligibility and Countable Income › Part 5 - COUNTABLE INCOME AND RESOURCES › Section 317:35-5-41.12 - Real or personal property essential to self-support

Current through Vol. 41, No. 20, July 1, 2024
(a) This rule describes exclusions when real
				  or personal property is essential to an individual's means of
				  self-support.
(b) Categories of
				  property essential to self-support.
(1)
				  Property used in a trade or business; property used by an individual as an
				  employee for work; or government permits that represent authority granted by a
				  government agency to engage in an income-producing activity.
(A) Are excluded as a resource regardless of
				  value or rate of return.
(B)
				  Government permits includes any permit, license, or similar instrument issued
				  by a federal, state, or local government agency.
(C) Personal property used by an employee for
				  work includes farm machinery, tools, safety equipment, uniforms,
				  etc.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 5 - Eligibility and Countable Income › Part 5 - COUNTABLE INCOME AND RESOURCES › Section 317:35-5-42 - Determination of countable income for individuals categorically related to aged, blind and disabled

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
The term income is defined as a gross gain or gross
				  recurrent benefit that derives from labor, business, property, retirement and
				  other benefits or sources that are available for use on a regular basis.
(1) If it appears the applicant or SoonerCare
				  member is eligible for any type of income [excluding Supplemental Security
				  Income (SSI)] or resources, Oklahoma Department of Human Services (OKDHS) staff
				  must notify the individual in writing of his/her potential eligibility, per
				  Section 416.210 of Title 20 of the Code of Federal Regulations (20 C.F.R. §
												416.210) .
(A) Potential income may include, but is not
				  limited to:
(i) Retirement, Survivors,
				  Disability Insurance (RSDI) benefits;
(ii) Benefits from the United States (U.S.)
				  Department of Veterans Affairs (VA);
(iii) Workers' compensation
				  payments;
(iv) Unemployment
				  insurance benefits (UIB);
(v)
				  Annuities;
(vi) Pensions or other
				  retirement benefits; or
(vii)
				  Disability benefits.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 5 - Eligibility and Countable Income › Part 5 - COUNTABLE INCOME AND RESOURCES › Section 317:35-5-43 - Third party resources; insurance, workers' compensation and Medicare

Current through Vol. 41, No. 20, July 1, 2024
Federal Regulations require that all reasonable measures to
					 ascertain legal liability of third parties to pay for care and services be
					 taken. In instances where such liability is found to exist after SoonerCare has
					 been made available, reimbursement to the extent of such legal liability must
					 be sought. The applicant or member must fully disclose to OHCA that another
					 resource may be available to pay for care. If OKDHS obtains information
					 regarding other available resources from a third party, the worker must
					 complete OKDHS Form 08AD050E, and submit to OHCA, Third Party Liability Unit.
					 Certification or payment in behalf of an eligible individual may not be
					 withheld because of the liability of a third party when such liability or the
					 amount cannot be currently established or is not currently available to pay the
					 individual's medical expense. The rules in this Section also apply when an
					 individual categorically related to pregnancy-related services plans to put the
					 child up for adoption. Any agreement with an adoption agency or attorneys shall
					 include payment of medical care and must be considered as a possibly liable
					 third party, regardless of whether agreement is made during prenatal, delivery
					 or postpartum periods.
(1)
Insurance.
(A)
Private
				  insurance.
An individual requesting SoonerCare is responsible for
				  identifying and providing information on any private medical insurance. He/she
				  is also responsible for reporting subsequent changes in insurance
				  coverage.
(B)
Government
				  benefits.
Individuals requesting SoonerCare who are also eligible for
				  Civilian Health and Medical Programs for Uniformed Services (CHAMPUS), must
				  disclose that the coverage is available. They are considered a third party
				  liability source.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 5 - Eligibility and Countable Income › Part 5 - COUNTABLE INCOME AND RESOURCES › Section 317:35-5-45 - Determination of income and resources for children and parents and caretaker relatives

Current through Vol. 41, No. 20, July 1, 2024
(a)
Prior
				  to October 1, 2013.
Income is determined in accordance with OAC
				  317:35-10 for individuals categorically related to AFDC. Unless questionable,
				  the income of categorically needy individuals who are categorically related to
				  AFDC does not require verification. Individuals categorically related to AFDC
				  are excluded from the AFDC resource test. Certain AFDC rules are specific to
				  money payment cases and are not applicable when only SoonerCare services are
				  requested. Exceptions to the AFDC rules are:
(1) the deeming of the parent(s)' income to
				  the minor parent;
(2) the deeming
				  of the sponsor's income to the sponsored alien;
(3) the deeming of stepparent income to the
				  stepchildren. The income of the stepparent who is not included for SoonerCare
				  in a family case is not deemed according to the stepparent liability. Only the
				  amount of the stepparent's contribution to the individual is considered as
				  income. The amount of contribution is determined according to OAC
				  317:35-10-26(a)(8),
				  Person acting in the role of a spouse;
(4) the AFDC lump sum income rule. For
				  purposes of SoonerCare eligibility, a period of ineligibility is not
				  computed;
(5) mandatory inclusion
				  of minor blood-related siblings or minor dependent children. For SoonerCare
				  purposes, the family has the option to exclude minor blood-related siblings
				  and/or minor dependent children;
(6) the disregard of one half of the earned
				  income;
(7) dependent care expense.
				  For SoonerCare only, dependent care expenses may be deducted for an in-home
				  provider who, though not approved, would have qualified had the qualification
				  process been followed;
(8) AFDC
				  trust rule. The availability of trusts for all SoonerCare only cases is
				  determined according to OAC
				  317:35-5-41.6;
(9) AFDC Striker rules. Striker status has no
				  bearing on SoonerCare eligibility;
(10) ET&E Sanction rule. The ET&E
				  status has no bearing on SoonerCare eligibility. However, a new SoonerCare
				  application is required.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 5 - Eligibility and Countable Income › Part 5 - COUNTABLE INCOME AND RESOURCES › Section 317:35-5-46 - Determination of income and resources for categorical relationship to pregnancy-related services

Current through Vol. 41, No. 20, July 1, 2024
(a)
Prior to
				  October 1, 2013.
Countable income for an individual categorically
				  related to pregnancy-related services is determined in the same manner as for
				  an individual categorically related to AFDC. (See OAC
				  317:35-5-45
				  ). Eligibility is based on the income received in the first month of
				  certification with changes in income not considered after certification.
				  Individuals categorically related to pregnancy-related services are excluded
				  from a resource test.
(b)
Effective October 1, 2013.
Income is determined in accordance with
				  the Modified Adjusted Gross Income (MAGI) methodology for individuals related
				  to the pregnancy group. See Subchapter 6 of this Chapter for MAGI rules.
				  Eligibility is based on the income received in the first month of certification
				  with changes in income not considered after certification, and there is no
				  resource test.
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 14 Ok Reg 56,
						eff 4-30-96 (emergency) ; Amended at 14 Ok Reg 1802, eff 5-27-97 ; Amended at
						16 Ok Reg 170, eff 11-1-98 (emergency) ; Amended at 16 Ok Reg 1438, eff 5-27-99
						; Amended at 20 Ok Reg 2775, eff 7-1-03 (emergency) ; Amended at 21 Ok Reg
						2234, eff 6-25-04 ; Amended at 25 Ok Reg 130, eff 8-1-07 (emergency) ; Amended
						at 25 Ok Reg 1257, eff 5-25-08 ; Amended at 26 Ok Reg 118, eff 10-1-08
						(emergency) ; Amended at 26 Ok Reg 1074, eff 5-11-09 ; Amended at 30 Ok Reg
						1209, eff 7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 5 - Eligibility and Countable Income › Part 5 - COUNTABLE INCOME AND RESOURCES › Section 317:35-5-48 - Determination of income and resources for categorical relationship to expansion adults

Current through Vol. 41, No. 20, July 1, 2024
Income is determined in accordance with the Modified
					 Adjusted Gross Income (MAGI) methodology for individuals related to expansion
					 adults. See Subchapter 6 of this Chapter for MAGI rules.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 5 - Eligibility and Countable Income › Part 5 - COUNTABLE INCOME AND RESOURCES › Section 317:35-5-47 - Determination of income and resources for categorical relationship to Disability for TB infected individuals

Current through Vol. 41, No. 20, July 1, 2024
Countable income and resources for an individual
					 categorically related because of a diagnosis of TB are determined in accordance
					 with rules for individuals determined aged, blind, or disabled. (See OAC
					 317:35-5-41
					 through
					 317:35-5-41.11
					 and
					 317:35-5-42.)
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 14 Ok Reg 56, eff 4-30-96 (emergency); Amended at 14 Ok Reg
					 1802, eff 5-27-97; Amended at 25 Ok Reg 130, eff 8-1-07 (emergency); Amended at
					 25 Ok Reg 1257, eff 5-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 5 - Eligibility and Countable Income › Part 5 - COUNTABLE INCOME AND RESOURCES › Section 317:35-5-49 - Determination of income and resources for categorical relationship to Tax Equity and Fiscal Responsibility Act (TEFRA)

Current through Vol. 41, No. 20, July 1, 2024
Countable income and resources for a child categorically
					 related to disability for TEFRA are determined in accordance with rules for
					 individuals determined aged, blind, or disabled (see Oklahoma Administrative
					 Code 317:35-5-41 through
					 317:35-5-41.11,
					 317:35-5-42, and
					 317:35-7-36 ). The family is
					 required to declare their household income so that the Oklahoma Health Care
					 Authority may determine if the child qualifies for the TEFRA program or is
					 otherwise SoonerCare eligible.
Added at 22 Ok Reg
					 2494, eff 7-11-05; Amended at 25 Ok Reg 130, eff 8-1-07 (emergency); Amended at
					 25 Ok Reg 1257, eff 5-25-08
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 5 - Eligibility and Countable Income › Part 7 - APPLICATION AND ELIGIBILITY DETERMINATION PROCEDURES › Section 317:35-5-61 - Reserved

Current through Vol. 41, No. 20, July 1, 2024
Added at 30 Ok Reg 1209, eff
						7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 5 - Eligibility and Countable Income › Part 7 - APPLICATION AND ELIGIBILITY DETERMINATION PROCEDURES › Section 317:35-5-62 - Reserved

Current through Vol. 41, No. 20, July 1, 2024
Reserved at 30 Ok Reg 1209, eff
						7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 5 - Eligibility and Countable Income › Part 7 - APPLICATION AND ELIGIBILITY DETERMINATION PROCEDURES › Section 317:35-5-63 - Agency responsible for determination of eligibility

Current through Vol. 41, No. 20, July 1, 2024
(a)
Determination of eligibility by
				  Oklahoma Health Care Authority (OHCA).
OHCA is responsible for
				  determining eligibility for the following eligibility groups:
(1) Children;
(2) Newborns deemed eligible;
(3) Pregnant women;
(4) Pregnancy-related services under Title
				  XXI;
(5) Parents and caretaker
				  relatives;
(6) Former foster care
				  children;
(7) Breast and Cervical
				  Cancer (BCC) treatment program;
(8)
				  SoonerPlan family planning program;
(9) Programs of All-Inclusive Care for the
				  Elderly(PACE); and
(10) Expansion
				  adults.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 5 - Eligibility and Countable Income › Part 7 - APPLICATION AND ELIGIBILITY DETERMINATION PROCEDURES › Section 317:35-5-64 - Cooperation in determination of eligibility

Current through Vol. 41, No. 20, July 1, 2024
(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.
Added at 30 Ok Reg 1209, eff
						7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 5 - Eligibility and Countable Income › Part 7 - APPLICATION AND ELIGIBILITY DETERMINATION PROCEDURES › Section 317:35-5-65 - Notification of eligibility

Current through Vol. 41, No. 20, July 1, 2024
When eligibility for SoonerCare is established, the
					 appropriate notice is computer generated to the applicant. When the computer
					 file is updated for changes, notices are generated only if there is a change in
					 the eligibility of any household member.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 5 - Eligibility and Countable Income › Part 7 - APPLICATION AND ELIGIBILITY DETERMINATION PROCEDURES › Section 317:35-5-66 - Electronic Notices

Current through Vol. 41, No. 20, July 1, 2024
(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.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 5 - Eligibility and Countable Income › Part 7 - APPLICATION AND ELIGIBILITY DETERMINATION PROCEDURES › Section 317:35-5-67 - Returned mail

Current through Vol. 41, No. 20, July 1, 2024
If the member's whereabouts are unknown, as indicated by
					 the return of unforwardable agency mail directed to the member, and the
					 Oklahoma Health Care Authority has made reasonable attempts to verify the
					 member's current address, the member's eligibility will be discontinued. Notice
					 thereof will be sent to the member by mail and by electronic notice. If the
					 member's whereabouts become known within the eligibility period, eligibility
					 shall be reinstated in accordance with Section 431.231(d) of Title 42 of the
					 Code of Federal Regulations. If the member's whereabouts become known after the
					 eligibility period, a new application will be required.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 6 - Soonercare for Pregnant Women and Families With Children › Part 1 - GENERAL › Section 317:35-6-1 - Scope and applicability

Current through Vol. 41, No. 20, July 1, 2024
(a)
				  The rules in this Subchapter apply when determining financial eligibility for
				  SoonerCare health benefits for groups whose eligibility is determined using
				  Modified Adjusted Gross Income (MAGI). These rules apply to the following
				  groups:
(1) Children;
(2) Pregnant women;
(3) Pregnancy-related services under Title
				  XXI;
(4) Parents and caretaker
				  relatives;
(5) SoonerPlan family
				  planning program;
(6) Independent
				  foster care adolescents;
(7)
				  Individuals under age twenty-one (21) in public psychiatric
				  facilities;
(8)
				  Tuberculosis;
(9) Former foster
				  care children;
(10) Children with
				  non-IV-E adoption assistance;
(11)
				  Individuals in adoptions subsidized in full or part by a public agency;
				  and
(12) Expansion
				  adults.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 6 - Soonercare for Pregnant Women and Families With Children › Part 3 - APPLICATION PROCEDURES › Section 317:35-6-15 - SoonerCare application for pregnant women, families with children, and expansion adults; forms

Current through Vol. 41, No. 20, July 1, 2024
(a)
Application.
An application for pregnant women, families with
				  children, and expansion adults consists of the SoonerCare 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. Individuals who wish to use a paper application form to apply for
				  coverage under a Modified Adjusted Gross Income (MAGI) eligibility group must
				  submit the federal Single Streamlined Application to apply for SoonerCare.
(1) An application may be made in a variety
				  of locations, for example, a physician's office, a hospital or other medical
				  facility, Oklahoma Department of Health, in the individual's county Oklahoma
				  Department of Human Services (OKDHS) office, or online. A face-to-face
				  interview is not required. Applications are mailed to the Oklahoma Health Care
				  Authority (OHCA) Eligibility Unit. When an individual indicates a need for
				  SoonerCare, the physician or facility may forward an application 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. 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 a SoonerCare 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) A
				  hospital providing services may file an electronic Notification of Date of
				  Service (NODOS) form with OHCA up to five (5) days from the date services are
				  rendered. The hospital, applicant, or someone acting on the applicant's behalf
				  has forty (40) days from the date the NODOS form was received by OHCA to submit
				  a completed SoonerCare application. Filing a NODOS does not guarantee coverage
				  and if a completed application is not submitted within forty (40) days, the
				  NODOS is void.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 6 - Soonercare for Pregnant Women and Families With Children › Part 3 - APPLICATION PROCEDURES › Section 317:35-6-15 - SoonerCare application for pregnant women, families with children, and expansion adults; forms

Current through Vol. 41, No. 20, July 1, 2024
(a)
Application.
An application for pregnant women, families with
				  children, and expansion adults consists of the SoonerCare 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. Individuals who wish to use a paper application form to apply for
				  coverage under a MAGI eligibility group must submit the federal Single
				  Streamlined Application to apply for SoonerCare.
(1) An application may be made in a variety
				  of locations, for example, a physician's office, a hospital or other medical
				  facility, Oklahoma Department of Health, in the individual's county Oklahoma
				  Department of Human Services (OKDHS) office, or online. A face-to-face
				  interview is not required. Applications are mailed to the OHCA Eligibility
				  Unit. When an individual indicates a need for SoonerCare, the physician or
				  facility may forward an application 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. 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 a SoonerCare 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) A
				  hospital providing services may file an electronic Notification of Date of
				  Service (NODOS) form with OHCA up to five(5) days from the date services are
				  rendered. The hospital, applicant, or someone acting on the applicant's behalf
				  has fifteen(15) days from the date the NODOS form was received by OHCA to
				  submit a completed SoonerCare application. Filing a NODOS does not guarantee
				  coverage and if a completed application is not submitted within fifteen(15)
				  days, the NODOS is void.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 6 - Soonercare for Pregnant Women and Families With Children › Part 5 - DETERMINATION OF ELIGIBILITY FOR SOONERCARE HEALTH BENEFITS FOR PREGNANT WOMEN AND FAMILIES WITH CHILDREN › Section 317:35-6-35 - General eligibility consideration

Current through Vol. 41, No. 20, July 1, 2024
(a)
Prior to October 1, 2013.
Financial eligibility for SoonerCare Health Benefits for Pregnant Women and
				  Families with Children is determined using the rules on income according to the
				  category to which the individual is related. (See Part 5, Subchapter 5 of this
				  Chapter.) Unless questionable, the income of categorically needy individuals
				  who are categorically related to AFDC does not require verification. There is
				  not a resource test for individuals categorically related to AFDC or pregnancy
				  related services.
(b)
Effective October 1, 2013.
Financial eligibility for SoonerCare
				  Health Benefits for MAGI eligibility groups is determined using the MAGI
				  methodology. Unless questionable, the income of individuals who are related to
				  a MAGI eligibility group does not require verification. There is no resource
				  test for individuals related to any of the MAGI groups (see Part 1 of this
				  Subchapter for a list of the MAGI groups).
(c) When medical assistance is requested on
				  behalf of any individual, eligibility is determined for that individual as well
				  as all other individuals in the family unit who meet basic criteria for a
				  SoonerCare eligibility group.
(d)
				  Income is evaluated on a monthly basis for all individuals included in the case
				  for Health Benefits.
Added at 16 Ok Reg 708, eff 1-1-99 (emergency) ; Added
						at 16 Ok Reg 1438, eff 5-27-99 ; Amended at 30 Ok Reg 1209, eff
						7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 6 - Soonercare for Pregnant Women and Families With Children › Part 5 - DETERMINATION OF ELIGIBILITY FOR SOONERCARE HEALTH BENEFITS FOR PREGNANT WOMEN AND FAMILIES WITH CHILDREN › Section 317:35-6-36 - Financial eligibility of individuals categorically related to aid to families with dependent children (AFDC), pregnancy-related services or expansion adults

Current through Vol. 41, No. 20, July 1, 2024
(a) When
				  determining financial eligibility for an individual related to AFDC,
				  pregnancy-related servicesor expansion adults, the income of the following
				  persons (if living together or if living apart as long as there has been no
				  break in the family relationship) are considered. These persons include the:
(1) Individual;
(2) Spouse of the individual;
(3) Biological or adoptive parent(s) of the
				  individual who is a minor dependent child. For health benefits only, income of
				  the stepparent of the minor dependent child is determined according to OAC
				  317:35-5-45;
(4) Minor dependent children of the
				  individual if the children are being included in the case for health benefits.
				  If the individual is nineteen (19) years or older and not pregnant, at least
				  one (1) minor dependent child must be living in the home and included in the
				  case for the individual to be related to AFDC;
(5) Blood related siblings, of the individual
				  who is a minor child, if they are included in the case for health benefits;
				  or
(6) Caretaker relative and
				  spouse (if any) and minor dependent children when the caretaker relative is to
				  be included for coverage.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 6 - Soonercare for Pregnant Women and Families With Children › Part 5 - DETERMINATION OF ELIGIBILITY FOR SOONERCARE HEALTH BENEFITS FOR PREGNANT WOMEN AND FAMILIES WITH CHILDREN › Section 317:35-6-37 - Financial eligibility of categorically needy individuals related to aid to families with dependent children (AFDC), pregnancy-related services, parent/caretaker relatives, families with children, and expansion adults

Current through Vol. 41, No. 20, July 1, 2024
Individuals whose income is less than the SoonerCare
					 income guidelines for the applicable eligibility group are financially eligible
					 for SoonerCare.
(1)
Categorically related to pregnancy-related services.
For an
				  individual related to pregnancy-related services to be financially eligible,
				  the countable income must be less than the appropriate standard according to
				  the family size on the SoonerCare income guidelines. In determining the
				  household size, the pregnant woman and her unborn child(ren) are
				  included.
(2)
Categorically
				  related to the children and parent/caretaker relative groups.
(A)
Parent/ caretaker relative
				  group.
For the individual in the parent/caretaker relative group to be
				  considered categorically needy, the SoonerCare income guidelines must be used.
(i) Individuals age nineteen (19) years or
				  older, other than pregnant women, are determined categorically needy if
				  countable income is equal to or less than the categorically needy standard,
				  according to the family size.
(ii)
				  All individuals under nineteen (19) years of age are determined categorically
				  needy if countable income is equal to or less than the categorically needy
				  standard, according to the size of the family.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 6 - Soonercare for Pregnant Women and Families With Children › Part 5 - DETERMINATION OF ELIGIBILITY FOR SOONERCARE HEALTH BENEFITS FOR PREGNANT WOMEN AND FAMILIES WITH CHILDREN › Section 317:35-6-38 - Hospital presumptive eligibility (HPE)

Current through Vol. 41, No. 20, July 1, 2024
(a)
General.
HPE is a limited
				  period of SoonerCare eligibility for individuals who are categorically related
				  to certain Modified Adjusted Gross Income (MAGI) eligibility groups listed in
				  OAC 317:35-6-38(a)(1)(A)(i) through (vi) and are also determined by a qualified
				  hospital [see OAC 317:35-6-38(a)(2)(A) through (L) for the conditions of a
				  qualified hospital], on the basis of preliminary information provided by the
				  applicant on a completed HPE application, to be eligible for SoonerCare
				  services. The rules in this Section apply only to those individuals applying
				  for, or qualified hospitals determining eligibility under, the HPE program.
(1)
Individuals eligible to participate
				  in the HPE program.
To be eligible to participate in the HPE program, an
				  individual must be categorically related to a MAGI eligibility group (see OAC
				  317:35-5-2
				  for categorical relationship criteria) and also meet the income standard and
				  non-medical eligibility specified in this Section.
(A)
MAGI eligibility groups.
The
				  following MAGI eligibility groups are eligible to have a presumptive
				  eligibility (PE) determination made by a qualified hospital participating in
				  the HPE program:
(i) Children;
(ii) Pregnant women;
(iii) Parent/caretaker relatives;
(iv) Expansion adults;
(v) Former foster care children;
(vi) Breast and Cervical Cancer(BCC)
				  treatment program; and
(vii)
				  SoonerPlan family planning program.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 6 - Soonercare for Pregnant Women and Families With Children › Part 5 - DETERMINATION OF ELIGIBILITY FOR SOONERCARE HEALTH BENEFITS FOR PREGNANT WOMEN AND FAMILIES WITH CHILDREN › Section 317:35-6-39 - General calculation of countable income for MAGI eligibility groups

Current through Vol. 41, No. 20, July 1, 2024
(a) The income that
				  is counted in determining eligibility for an individual is that individual's
				  household income.
(b) In order to
				  calculate the countable household income for an individual:
(1) Determine who is in the individual's
				  household (see OAC
				  317:35-6-40
				  to
				  317:35-6-43
				  );
(2) Identify all sources of
				  income for all household members;
(3) Determine whether each source of income
				  is considered for SoonerCare eligibility or is excluded (see Part 6, Countable
				  Income, of this Subchapter);
(4)
				  Determine the gross monthly amount of each source of countable income (see Part
				  6, Countable Income, of this subchapter);
(5) Determine whether each household member's
				  income counts toward the household (see
				  317:35-6-44
				  );
(6) Sum the gross monthly
				  amounts of all countable sources of income of all household members whose
				  income is counted;
(7) Subtract
				  allowable adjustments to income (see OAC
				  317:35-6-52
				  ); and
(8) Compare the result to
				  the income limit for the individual's eligibility group (see SoonerCare Income
				  Guidelines). If the result is equal to or less than the dollar amount of the
				  income limit, the individual is financially eligible.
(9) When calculating the percentage of the
				  Federal Poverty Level (FPL) that corresponds to the individual's monthly
				  countable income, subtract 5% from the FPL percentage reached to determine the
				  countable FPL level for the individual. This countable percentage of FPL is
				  compared to the FPL limit for the individual's eligibility group in order to
				  determine whether the individual is financially eligible. This 5% deduction
				  from FPL has already been accounted for in the dollar amounts of the income
				  limits given in the SoonerCare Income Guidelines.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 6 - Soonercare for Pregnant Women and Families With Children › Part 5 - DETERMINATION OF ELIGIBILITY FOR SOONERCARE HEALTH BENEFITS FOR PREGNANT WOMEN AND FAMILIES WITH CHILDREN › Section 317:35-6-40 - MAGI household composition; taxpayers and tax dependents

Current through Vol. 41, No. 20, July 1, 2024
(a) The rules used
				  to determine MAGI household composition depend on tax relationships.
(b) Whether an individual is a taxpayer or a
				  tax dependent at the time of application is determined by whether the applicant
				  expects to file taxes or expects to be claimed as a tax dependent by another
				  taxpayer for the current tax year in which the determination of eligibility for
				  SoonerCare is made.
Added at 30 Ok Reg 1209, eff
						7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 6 - Soonercare for Pregnant Women and Families With Children › Part 5 - DETERMINATION OF ELIGIBILITY FOR SOONERCARE HEALTH BENEFITS FOR PREGNANT WOMEN AND FAMILIES WITH CHILDREN › Section 317:35-6-41 - MAGI household composition; tax filers

Current through Vol. 41, No. 20, July 1, 2024
(a)
Scope.
This section applies
				  to individuals who expect to file taxes themselves or who expect to be claimed
				  by another taxpayer as a tax dependent for the taxable year in which the
				  eligibility determination is being made.
(b)
Taxpayers.
The household of
				  an individual who expects to be a taxpayer consists of him or herself and all
				  of the tax dependents he or she expects to claim.
(c)
Tax dependents.
If an
				  individual expects to be both a taxpayer and a tax dependent, the individual is
				  considered a tax dependent. Unless an exception listed in OAC
				  317:35-6-42
				  applies, the household of an individual who expects to be claimed as a tax
				  dependent consists of the taxpayer claiming him or her and all other dependents
				  expected to be claimed by that taxpayer.
(d)
Spouses.
Spouses who live
				  together are always counted in each other's households, regardless of whether
				  or how they expect to file taxes, and regardless of whether one or both of them
				  expect to be claimed as a tax dependent by another taxpayer.
(e)
Unborn children.
If any
				  member of the household is pregnant, the number of children she expects to
				  deliver is counted in the household size of all households of which she is a
				  member.
(f)
No option to
				  exclude.
Individuals may not choose to exclude any person counted as a
				  household member under this rule from the household.
Added at 30 Ok Reg 1209, eff
						7-1-13
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 6 - Soonercare for Pregnant Women and Families With Children › Part 5 - DETERMINATION OF ELIGIBILITY FOR SOONERCARE HEALTH BENEFITS FOR PREGNANT WOMEN AND FAMILIES WITH CHILDREN › Section 317:35-6-42 - MAGI household composition; exceptions to tax filer rules

Current through Vol. 41, No. 20, July 1, 2024
(a) The tax filer
				  household composition rules in OAC
				  317:35-6-41
				  do not apply to the following individuals:
(1) Individuals who expect to be claimed as a
				  tax dependent by a taxpayer who is not their spouse or biological, adoptive, or
				  step parent, regardless of the individual's age;
(2) Individuals under the age of 19 who are
				  living with two parents, whose parents do not expect to file a joint return,
				  and who expect to be claimed as a dependent by one of their parents;
				  or
(3) Individuals under the age of
				  19 who expect to be claimed as a tax dependent by a non-custodial
				  parent.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 6 - Soonercare for Pregnant Women and Families With Children › Part 5 - DETERMINATION OF ELIGIBILITY FOR SOONERCARE HEALTH BENEFITS FOR PREGNANT WOMEN AND FAMILIES WITH CHILDREN › Section 317:35-6-43 - MAGI household composition; non-filers

Current through Vol. 41, No. 20, July 1, 2024
(a) The household composition defined in this
				  section applies to individuals who do not expect to file taxes and do not
				  expect to be claimed as a tax dependent by another taxpayer for the taxable
				  year during which eligibility is being determined. This section also applies to
				  individuals described in an exception to the tax filer household in OAC
				  317:35-6-42.
(b) The non-filer household consists of the
				  individual, and if applicable and if living with the individual:
(1) the individual's spouse;
(2) the individual's natural, adopted and
				  step children under the age of 19;
(3) if the individual is under the age of 19,
				  the individual's natural, adoptive and step parents; and
(4) if the individual is under the age of 19,
				  the individual's natural, adoptive and step siblings who are also under the age
				  of 19.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 6 - Soonercare for Pregnant Women and Families With Children › Part 5 - DETERMINATION OF ELIGIBILITY FOR SOONERCARE HEALTH BENEFITS FOR PREGNANT WOMEN AND FAMILIES WITH CHILDREN › Section 317:35-6-44 - Determination of whether a household member's income is counted

Current through Vol. 41, No. 20, July 1, 2024
(a) Unless a
				  household member falls into an exception listed in this Section, his or her
				  income counts for him or herself and for all members of all households of which
				  the individual is a member.
(b) The
				  income of the following individuals is not included in household income of the
				  household to which the exception applies:
(1)
				  Individuals included in a household of which their biological, adoptive or step
				  parent(s) is/are also member(s), who are not expected to be required to file a
				  tax return for the tax year during which eligibility is being determined
				  (regardless of whether the individual later does in fact file a tax return, and
				  regardless of the individual's age); and
(2) Individuals claimed as tax dependents by
				  someone other than their spouse or biological, adoptive or step parent who are
				  not expected to be required to file a tax return for the tax year during which
				  eligibility is being determined (regardless of whether the individual does in
				  fact file a tax return, and regardless of the individual's age).
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 6 - Soonercare for Pregnant Women and Families With Children › Part 5 - DETERMINATION OF ELIGIBILITY FOR SOONERCARE HEALTH BENEFITS FOR PREGNANT WOMEN AND FAMILIES WITH CHILDREN › Section 317:35-6-45 - Eligibility for inmates

Current through Vol. 41, No. 20, July 1, 2024
(a) The Oklahoma
				  Health Care Authority (OHCA) shall receive applications from and make
				  eligibility determinations for individuals residing in correctional
				  institutions, including juvenile facilities. However, the SoonerCare program
				  will only pay for services rendered to individuals residing in a correctional
				  institution as specified in Oklahoma Administrative Code (OAC)
				  317:35-5-26.
(b) In accordance with federal
				  law, including, but not limited to, 42 United States Code (U.S.C.) §
				  1396a(a)(84), individuals residing in correctional institutions who are under
				  the age of twenty-one (21) or who meet the former foster care child
				  requirements found at OAC
				  317:35-5-2,
				  shall have their eligibility suspended for the duration of the incarceration
				  period, except for periods of time that inpatient services are provided as
				  specified in OAC
				  317:35-5-26.
(c) The effective date of the
				  suspension is the calendar day following the date on which an individual
				  described in (b) of this section becomes incarcerated.
(d) A redetermination of eligibility for an
				  individual described in (b) of this section shall be conducted prior to release
				  to determine if the individual continues to meet the eligibility requirements
				  for SoonerCare. A new application will not be required to redetermine
				  eligibility.
(e) Suspended
				  eligibility shall be restored to the release date after a redetermination of
				  eligibility, when:
(1) The Oklahoma
				  Department of Human Services (OKDHS), using the release date supplied by the
				  Oklahoma Office of Juvenile Affairs (OJA) or the Oklahoma Department of
				  Corrections (DOC), removes the suspension;
(2) The individual reports his or her release
				  to the Oklahoma Health Care Authority (OHCA) within ten (10) calendar days of
				  the release date; or
(3) The
				  individual reports his or her release to OHCA more than ten (10) calendar days
				  from the release date, and there is good cause for the delay in reporting.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 6 - Soonercare for Pregnant Women and Families With Children › Part 6 - COUNTABLE INCOME FOR MAGI › Section 317:35-6-50 - Countable sources of income

Current through Vol. 41, No. 20, July 1, 2024
Unless an exception listed in OAC
					 317:35-6-51
					 applies, all income included in Modified Adjusted Gross Income in Section 36B
					 of the Internal Revenue Code is included in the MAGI calculation for SoonerCare
					 eligibility.
Added at 30 Ok Reg 1209, eff
						7-1-13