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.
"Continuous eligibility"
means uninterrupted
				  eligibility for the extent of the certification period regardless of any
				  changes in circumstances, unless:
(A)
				The child turns age nineteen (19);
(B) The child dies;
(C) The child is no longer an Oklahoma
				resident;
(D) The child becomes
				incarcerated (per OAC
				317:35-6-45 the eligibility is
				suspended for the duration of the incarceration period for individuals under
				the age of twenty-one (21) except for periods of time that inpatient services
				are provided per OAC
				317:35-5-26);
(E) The adult parent or caretaker relative on
				the case requests that the medical benefits are closed;
(F) The state has erred in the eligibility
				determination;
(G) The child or the
				adult parent or caretaker relative on the case has committed fraud or perjury
				in order to become eligible; or
(H)
				The child becomes categorically related to either the pregnancy eligibility
				group or the former foster care eligibility groups, thereby receiving
				eligibility based on such category, which is not considered an interruption in
				continuous eligibility.
"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.
"Minor child"
means a child under the age of
				  eighteen (18).
(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.