Library: Policy
317:35-19-19. General financial eligibility requirements for NF and skilled nursing care
Revised 6-1-21
(a) Financial eligibility for NF care. Financial eligibility for NF care is determined using the rules on income and resources according to the eligibility group to which the individual is related.
(1) Income, resources and expenses are evaluated on a monthly basis for all individuals requesting payment for NF care. Each individual requesting payment for NF care is allowed a personal needs allowance.
(2) To be eligible for long-term care in an NF, the individual must be determined categorically needy according to the standards appropriate to the categorical relationship.
(3) If the individual's gross income exceeds the categorically needy standard as shown on OKDHS Appendix C-1, Schedule VIII. B. 1., refer to OAC 317:35-5-41.6(a)(6)(B) for rules on establishing a Medicaid Income Pension Trust.
(4) When eligibility for long-term care has been determined, the spenddown amount is determined based on type of care, categorical relationship, community spouse, etc.
(5) The spenddown is applied to the vendor payment on the first NF claim(s) received on behalf of the individual.
(6) For an individual eligible for long-term care in a NF, the individual's share of the vendor payment is not prorated over the month. As SoonerCare is the payer of last resort, the full amount of the member's share of the vendor payment must first be applied to the facility's charges before SoonerCare reimbursement begins.
(b) Financial eligibility for skilled nursing. Skilled Nursing Care is covered as part of the Medicare Part A coverage. For members who are currently receiving this benefit through the QMB program, no further action is needed. For individuals who do not have an active SoonerCare case, an application is processed to receive the Medicare crossover and deductible benefits. • 1 Income eligibility is based on the categorically needy standard in OKDHS Appendix C-1, Schedule VI., for the first 30 days. After the initial 30 days, income eligibility is based on the categorically needy standard in OKDHS Appendix C-1, Schedule VIII. B. 1.
(1) QMB eligible individuals in skilled nursing care are allowed the resource standard as shown on OKDHS Appendix C-1, Schedule VI, but must meet the SoonerCare resource standard as shown on OKDHS Appendix C-1, Schedule VIII. D., for NF level of care. For individuals with no active case, use the resource standard shown on OKDHS Appendix C-1, Schedule VIII. D. • 2
(2) Rules concerning transfer of assets do not apply to skilled level of care.
INSTRUCTIONS TO STAFF 317:35-19-19
Revised 6-1-21
1. (a) Persons who are enrolled in Medicare Part A are eligible for a skilled care payment. Refer to Quest article, "Skilled Care Overview".
(1) Medicare Part A pays for the first 20-calendar days of skilled care.
(2) It is only necessary to process a SoonerCare (Medicaid) application when the individual remains in skilled care longer than 20-calendar days so the Oklahoma Health Care Authority (OHCA) can pay the coinsurance for the days exceeding 20-calendar days.
(3) The provider bills OHCA for the coinsurance so it is not necessary to enter an authorization for skilled care in the Family Assistance/Client Services (FACS) system.
(b) When the individual's income is over the long-term-care categorically needy income standard, per Oklahoma Human Services (OKDHS) Appendix C-1, Maximum Income, Resource, and Payment Standards, Schedule VIII. B.1, a Medicaid Income Pension Trust (MIPT) can be established to be effective on the 31st day of skilled care. The MIPT must be both set up and funded by the 31st day in skilled care in order for the person to be eligible beginning on the 31st day.
2. When the individual remains in skilled care longer than 20-calendar days but less than 30-calendar days, the individual must meet the Qualified Medicare Beneficiary Plus standard, per OKDHS Appendix C-1, Schedule VI.
