OHCA Policies and Rules
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.
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.
