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Library: Policy

317:35-7-60. Certification for SoonerCare

Revised 7-1-21

(a) General.  The rules in this Section apply to the following categories of eligibles:

(1) Categorically needy SoonerCare members who are categorically related to Aged, Blind, and Disabled (ABD);

(2) Categorically needy SoonerCare members who are categorically related to ABD, and are eligible for one of the following:

(A) Qualified Medicare Beneficiary Plus (QMBP);

(B) Qualified Disabled and Working Individual (QDWI);

(C) Specified Low-Income Medicare Beneficiary (SLMB);

(D) Tuberculosis (TB) related services;

(E) Qualifying Individual (QI); or

(F) Tax Equity and Fiscal Responsibility Act (TEFRA).

(b) Certification of individuals categorically needy and categorically related to ABD.  The certification period for the categorically needy individual who is categorically related to ABD can be up to twelve (12) months from the date of certification. The individual must meet all factors of eligibility for each month of the certification period. The certification can be for a retroactive period of coverage, during the three (3) months directly before the month of application, if the individual received covered medical services at any time during those three (3) months and would have been eligible for SoonerCare at the time he or she received the services. The cash payment portion of the State Supplemental Payment (SSP) may not be paid for any period prior to the month of application.

(1) The certification period is twelve (12) months unless the individual:

(A) Is certified as eligible in a money payment case during the twelve (12) month period;

(B) Is certified for long-term care during the twelve (12) month period;

(C) Becomes ineligible for medical assistance after the initial month;

(D) Becomes ineligible as categorically needy; or

(E) Is deceased.

(2) If any of the situations listed in subparagraph (1) of this paragraph occur after the initial month, the case is closed by the worker.

(A) If income and/or resources change after certification causing the case to exceed the categorically needy maximums, the case is closed.

(B) A pregnant individual included in an ABD case which closes continues to be eligible for pregnancy related services through the postpartum period.

(c) Certification of individuals categorically related to ABD and eligible as QMBP.  The SoonerCare benefit may be certified on the first day of the third month prior to the month of application or later. If the individual receives Medicare and is eligible for SSP, the effective date of certification for the Medicare Part B premium buy-in is the month of certification for SSP. If the individual receives Medicare and is not eligible for SSP, the effective date of certification for the Medicare Part B premium buy-in is the first day of the month following the month in which the eligibility determination is made (regardless of when application was made).

(1) An individual determined eligible for QMBP benefits is assigned a certification period of twelve (12) months. At any time during the certification period that the individual becomes ineligible, the case is closed using regular negative action procedures.

(2) At the end of the certification period a redetermination of QMBP eligibility is required, using the same forms and procedures as for ABD categorically needy individuals.

(d) Certification of individuals categorically related to ABD and eligible as QDWI.  The Social Security Administration (SSA) is responsible for referrals of individuals potentially eligible for QDWI. Eligibility factors verified by the SSA are Medicare Part A eligibility and discontinuation of disability benefits due to excessive earnings. When the OKDHS State office receives referrals from the SSA, the county will be notified and is responsible for obtaining an application and establishing other factors of eligibility. If an individual contacts the county office stating he/she has been advised by SSA that he/she is a potential QDWI, the county takes a SoonerCare application. The effective date of certification for QDWI benefits is based on the date of application and the date all eligibility criteria, including enrollment for Medicare Part A, are met. For example, if an individual applies for benefits in October and is already enrolled in Medicare Part A, eligibility can be effective October 1 [or up to three (3) months prior to October 1, if all eligibility criteria are met during the three (3) month period]. However, if in the example, the individual's enrollment for Part A is not effective until November 1, eligibility cannot be effective until that date. Eligibility can never be effective prior to July 1, 1990, the effective date of this provision. These cases will be certified for a period of twelve (12) months. At the end of the twelve (12) month period, eligibility redetermination is required. If the individual becomes ineligible at any time during the certification period, the case is closed.

(e) Certification of individuals categorically related to ABD and eligible as SLMB. The effective date of certification of SLMB benefits may begin on the first day of the third month prior to the month of application or later. A certification can never be earlier than the date of entitlement of Medicare Part A. An individual determined eligible for SLMB benefits is assigned a certification period of twelve (12) months. At any time during the certification period the individual becomes ineligible, the case is closed using standard negative action procedures. At the end of the certification period a redetermination of SLMB eligibility is required. A redetermination of SLMB eligibility must also be done at the same time a dually eligible individual has a redetermination of eligibility for other SoonerCare benefits such as long-term care.

(f) Certification of individuals categorically related to disability and eligible for TB related services.

(1) An individual determined eligible for TB related services may be certified the first day of the third month prior to the month of application or later, but no earlier than the first day of the month the TB infection is diagnosed.

(2) A certification period of twelve (12) months will be assigned. At any time during the certification period that the individual becomes ineligible, the case is closed using the regular negative action procedures.

(3) At the end of the certification period a new application will be required if additional treatment is needed.

(g) Certification of individuals categorically related to ABD and eligible as QI.  The effective date of certification for the QI-1 may begin on the first day of the third month prior to the month of application or later. A certification can never be earlier than the date of entitlement of Medicare Part A. An individual determined eligible for QI benefits is assigned a certification period of twelve (12) months. At any time during the certification period the individual becomes ineligible, the case is closed using standard negative action procedures. At the end of the certification period, a redetermination of QI eligibility is required.

(1) Since the State's allotment to pay Medicare premiums for this group of individuals is limited, the State must limit the number of QIs so that the amount of assistance provided during the year does not exceed the State's allotment for that year.

(2) Persons selected to receive assistance are entitled to receive assistance with their Medicare premiums for the remainder of the federal fiscal year, but not beyond, as long as they continue to qualify. The fact that an individual is selected to receive assistance at any time during the year does not entitle the individual to continued assistance for any succeeding year.

(h) Certification of individuals related to Aid to the Disabled for TEFRA.  The certification period for individuals categorically related to the Disabled for TEFRA is twelve (12) months.

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