Library: Policy

317:35-9-65. General financial eligibility requirements for ICF/MR, HCBW/MR and individuals age 65 or older in mental health hospitals

Revised 6-25-09

Financial eligibility for these types of long-term medical care is determined using the rules on income and resources according to OAC 317:35-7-36.

(1) Income, resources and expenses are evaluated on a monthly basis for all individuals requesting payment for long-term medical care.
(2) To be eligible for long-term care in an ICF/MR (private and public), HCBW/MR services and for persons 65 years or older in mental health hospitals, the individual must be determined categorically needy.
(3) If the individual's gross income exceeds the categorically needy standard as shown on OKDHS Form 08AX001E, 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 vendor payment amount, if applicable, is determined based on type of care, community spouse, etc. • 1 Individuals determined eligible for HCBW/MR services will not have a vendor payment.
(5) The vendor payment is applied to the first claim(s) received on behalf of the individual.
(6) For an individual eligible for long-term care in an ICF/MR (private and public) or for an individual 65 years or older in a mental health hospital, the vendor payment is not prorated over the month. As SoonerCare is the payer of last resort, the full amount of the vendor payment must first be applied to the facility's charges before SoonerCare reimbursement begins.

INSTRUCTIONS TO STAFF 317:35-9-65

1.See the Instructions to Staff for OAC 317:35-9-68 for calculation of the vendor payment.