Library: Policy
317:35-17-1. Overview of long-term medical care services; relationship to Qualified Medicare Beneficiary Plus (QMBP), Specified Low-Income Medicare Beneficiary (SLMB), and other Medicaid (SoonerCare) services eligibility
Revised 9-14-20
(a) Long-term medical care for the categorically needy includes:
(1) Care in a long-term care facility per Oklahoma Administrative Code (OAC) 317:35-19;
(2) Care in a public or private intermediate care facility for the intellectually disabled (ICF/IID), per OAC 317:35-9;
(3) Care of persons sixty-five (65) years of age and older in mental health hospitals, per OAC 317:35-9;
(4) Home and Community-Based waiver services for persons with intellectual disabilities, per OAC 317:35-9;
(5) Personal Care services, per OAC 317:35-15; and
(6) Home and Community-Based waiver services (ADvantage waiver) for frail elderly, sixty-five (65) years of age and older; and a targeted group of adults with physical disabilities, twenty-one (21) to sixty-four (64) years of age and older, who do not have an intellectual disability or a cognitive impairment related to a developmental disability per OAC 317:35-17-3.
(b) When an individual is certified as eligible for SoonerCare coverage of long-term care, he or she is also eligible for other SoonerCare services. ADvantage waiver members do not have a copayment for ADvantage services except for prescription drugs. For members residing in an ADvantage assisted living center, any income beyond one-hundred and fifty percent (150%) of the federal benefit rate is available to defray the cost of the assisted living services received. The member is responsible for payment to the assisted living services center provider for days of service, from the first day of each full-month in which services were received, until the vendor pay obligation is met. When an individual is aged, blind, or disabled and is determined eligible for long-term care, a separate eligibility determination must be made for QMBP or SLMB benefits. • 1 An ADvantage program member may reside in a licensed assisted living services center only when the assisted living services center is a certified ADvantage assisted living services center provider from whom the member is receiving ADvantage assisted living services.
INSTRUCTIONS TO STAFF 317:35-17-1
Issued 12-15-20
1. When a married applicant applies for ADvantage waiver services and is determined financially and medically eligible for the program, the worker separates the couple's income and resources to make a Qualified Medicare Beneficiary Plus (QMBP) and Specified Low Income Medicare Beneficiary (SLMB) determination for each person based on the individual income and resource standards, per Oklahoma Human Services (OKDHS) Appendix C-1, Maximum Income, Resource, and Payment Standards, Schedule VI and VII, instead of the couple standard. The worker codes each person as "Married But Involuntarily Separated (MP)" in the "marital status" field of the Household tab in the Family Assistance/Client Services Interview Notebook. The worker does not separate the couple's income and resources to determine their eligibility for State Supplemental Payment or State Plan Personal Care.
(1) Example: A wife receives $900 Retirement, Survivors, and Disability Insurance (RSDI) benefits and her husband receives $1,100 RSDI benefits. They are not eligible for QMBP or SLMB based on the income and resource standards for couples, per OKDHS Appendix C-1, Schedule VI and VII. The wife applies for ADvantage waiver services and is determined financially and medically eligible for the program. The couple's income and resources can now be separated to determine their individual eligibility for QMBP and SLMB. The worker codes each person as MP in the "marital status" field. In this example, the wife is now eligible for the Medicare Part B premium payment (Buy-In) under QMBP using the individual income standard, per OKDHS Appendix C-1, Schedule VI. Her ADvantage waiver approval covers Medicaid services. The husband does not qualify for QMBP, but does qualify for SLMB using the individual income standard, per OKDHS Appendix C-1, Schedule VII, if he is approved for Medicare. The worker uses the individual resource standard to determine resource eligibility for each person.
(2) Example: A wife receives $1,500 RSDI benefits and her husband receives $900 RSDI benefits. They are not eligible for QMBP or SLMB based on the income and resource standards for couples, per OKDHS Appendix C-1, Schedule VI and VII. The wife applies for ADvantage waiver services and is determined financially and medically eligible for the program. The couple's income and resources can now be separated to determine their individual eligibility for QMBP and SLMB. The worker codes each person as MP in the "marital status" field. The wife does not qualify for the Medicare Part B premium payment (Buy-In) under QMBP or SLMB based on the individual income standard, per OKDHS Appendix C-1, Schedule VI and VII. Her Advantage waiver approval covers Medicaid services. The husband qualifies for QMBP based on the individual income standard, per OKDHS Appendix C-1, Schedule VI. The worker uses the individual resource standard to determine resource eligibility for each person.
