SECTION 317:35-7-60. Certification for SoonerCare

(a)   The rules in this Section apply to all categories of eligibles EXCEPT:

(1)   categorically needy SoonerCare members who are categorically related to AFDC or Pregnancy Related Services, AND

(2)   who if eligible, would be enrolled in SoonerCare, or

(3)   individuals categorically related to the Family Planning Program.

(b)   An individual determined eligible for SoonerCare may be certified for a medical service provided on or after the first day of the third month prior to the month of application if all eligibility criteria are met during the three month period. The certification period is determined beginning with the month the medical service was received or expected to be received or the month of application for categorically needy cases in which a medical service has not been received. The period of certification may cover retroactive or future months.

(1)   Certification as categorically needy. A categorically needy individual who is categorically related to ABD is assigned a certification period of 12 months. A categorically needy individual who is determined eligible for a State Supplemental Payment (SSP) is certified effective the month of application. If the individual is also eligible for payment for medical services received during the three months preceding the month of application, the SoonerCare benefit is certified for the appropriate months. If the individual is not eligible for SSP, the first month of certification is the month that a medical service was provided or, if no medical service was provided, the month of application.

(A)   Certification of individuals categorically needy and categorically related to ABD. The certification period for the individual categorically related to ABD can be assigned for up to 12 months. The individual must be determined as categorically needy for each month of the certification period. The certification period is 12 months unless the individual:

(i)   is certified as eligible in a money payment case during the 12 month period;

(ii)   is certified for long-term care during the 12 month period;

(iii)   becomes ineligible for medical assistance after the initial month;

(iv)   becomes ineligible as categorically needy; or

(v)   is deceased.

(B)   Certification period. If any of the situations listed in subparagraph (A) of this paragraph occur after the initial month, the case is closed by the worker.

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

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

(2)   Certification of individuals categorically related to ABD and eligible as Qualified Medicare Beneficiaries Plus. 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).

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

(B)   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.

(3)   Certification of individuals categorically related to ABD and eligible as Qualified Disabled and Working Individual. The Social Security Administration 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 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 months prior to October 1, if all eligibility criteria are met during the three 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 12 months. At the end of the 12-month period, eligibility redetermination is required. If the individual becomes ineligible at any time during the certification period, the case is closed.

(4)   Certification of individuals categorically related to ABD and eligible as Specified Low-Income Medicare Beneficiary (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 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.

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

(A)   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.

(B)   A certification period of 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.

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

(6)   Certification of individuals categorically related to ABD and eligible as Qualifying Individuals. 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 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.

(A)   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.

(B)   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.

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

[Source: Amended at 16 Ok Reg 60, eff 9-11-98 (emergency); Added at 12 Ok Reg 753, eff 1-6-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3133, eff 7-27-95; Amended at 14 Ok Reg 56, eff 4-30-96 (emergency); Amended at 14 Ok Reg 1802, eff 5-27-97; Amended at 15 Ok Reg 3679, eff 5-18-98 (emergency); Amended at 16 Ok Reg 60, eff 9-11-98; Amended at 16 Ok Reg 708, eff 1-1-99 (emergency); Amended at 16 Ok Reg 1438, eff 5-27-99; Amended at 18 Ok Reg 114, eff 11-1-00 (emergency); Amended at 18 Ok Reg 1139, eff 5-11-01; Amended at 20 Ok Reg 646, eff 2-1-03 (emergency); Amended at 20 Ok Reg 1943, eff 6-26-03; Amended at 20 Ok Reg 2775, eff 7-1-03 (emergency); Amended at 21 Ok Reg 2234, eff 6-25-04; Amended at 22 Ok Reg 1012, eff 4-1-05 (emergency); Amended at 22 Ok Reg 2518, eff 7-11-05; Amended at 29 Ok Reg 1149, eff 6-25-12]