(a) In order for a child to be eligible for TEFRA, he/she must require a level of care provided in an acute care hospital for a minimum of sixty (60) days, or a nursing facility (NF) or intermediate care facility for individuals with intellectual disabilities (ICF/IID) for a minimum of thirty (30) days. In order to determine nursing facility level of care for TEFRA children: (1) The child must be age 18 years or younger and expected to meet the following criteria for a minimum of 30 days. SSA does not make disability decisions on individuals who: (i) have been determined ineligible by SSA on some condition of eligibility other than disability, (ii) have unearned income in excess of the SSI standard and, therefore, are not referred to SSA, or. 0000058993 00000 n 30 0 obj<> endobj 0000003681 00000 n <<9a89c52ff011cb4bbf1d81e0b851b22f>]>> endstream endobj 44 0 obj<> endobj 45 0 obj<>stream 0000003114 00000 n (C) A request for additional medical and/or social information when additional information is necessary for a decision. (a) In order for a child to be eligible for TEFRA, he/she must require a level of care provided in an acute care hospital for a minimum of sixty (60) days, or a nursing facility (NF) or intermediate care facility for individuals with intellectual disabilities (ICF/IID) for a minimum of thirty (30) days. Categorical relationship to the disabled is automatically established if an individual dies while receiving a medical service or dies as a result of an illness for which he/she was hospitalized if death occurs within two (2) months after hospital release. Once completed by the physician and returned to the Oklahoma Health Care Authority, the assessment form is forwarded to the LOCEU along with the request for a disability determination (if needed). Copies of medical and hospital bill and DHS Form 08MA005E are not normally considered pertinent medical information by themselves. Oklahoma Health Care Authority SoonerCare Demonstration 11-W-00048/6 §1115(a) Quarterly Report . The case record is documented to show the individual agrees with the short term duration. xref • … There were 14,823 households, out of which … If he/she has been determined ineligible, the payment status code for ineligibility is shown. Well-child visits are more comprehensive than a physical and are a time for the doctor to make sure … (2) The services needed by the child must be greater than the services provided by an ICF/IID and less than those provided in a hospital. 0000001698 00000 n H�\V TTW����ݭB���؊D�7D��W4 x�v+ ((F�-�{�1�d\3�q9�������q����1��0�r�q9�������w~�z�꽪���v� �#H8�u⨫�#�>�xu��BO�ֶC= �1zr�޿&{��u�Ec Note: As soon as your medical bills reach your spend-down amount, you can get Medicaid. Current (less than ninety (90) days old) medical information is required for the LOCEU to make a decision on the client's current disability status. I. 94.8% spoke English, 2.1% Cherokee, 1.4% Spanish and 1.2% German as their first language. (a) For applications made prior to January 1, 2014, categorical relationship to pregnancy-related services can be established by determining through medical evidence that the individual is currently or has been pregnant. • Third Party Liability. As one of the few states that maintains separate control over its … • Mental Health and Substance Abuse. Effective 12/01/1997, the state expanded its coverage of children and pregnant women to include … Eligibility – Should be checked on each visit. trailer If the parent or caretaker relative is claiming good cause, he/she cannot be certified for SoonerCare in the parent and caretaker relative group unless OCSS has determined good cause exists. The individual must also provide the expected date of delivery. The expected date of delivery must be established either by information from the applicant's physician or other qualified practitioner. SoonerCare Choice Percentage of total Medicaid Population 70% . II, 31 U.S.C. If an individual becomes retroactively eligible for SSA/SSI due to a decision on an appeal, categorical relationship is established as of the effective date of the retroactive disability decision. (iii) do not have a disability which would normally be expected to last twelve (12) months but the applicant disagrees. SoonerCare covers pharmacy, behavioral health, specialty and regular doctor visits at no copay to the foster parent. If the reason for SSI ineligibility was based on some reason other than failure to meet the disability definition (and therefore, a determination of disability was not made), the Level of Care Evaluation Unit (LOCEU) must determine categorical relationship. (a) In order to be eligible for SoonerCare, an individual must first meet the description of a member eligibility group. The program, which was created by Congress in 1965 as Title XIX of the Social Security Act, is operated by the states and funded jointly by the federal government and the states. (D) Already determined ineligible for SSI. (a) For applications made prior to January 1, 2014, categorical relationship for pregnancy related benefits covered under Title XXI is determined in accordance with OAC 317:35-22-1 and through medical evidence that the individual is currently or has recently been pregnant and may qualify for pregnancy related services. Search Email. �e�Y���Vcv�_!U(����KToN��nf"�,y᭰�S�)dg�kĀ����� ���(e �4`L�`��сd1�30�� ���X,��Ǽ�WCx� ;P�\F+�� � � � ,�~��EX��z�r���S�{LL;D��8y�tA� ����H�00���=&����68�� �F; For an individual to be related to the former foster care children group, the individual must not be eligible for the Title XIX pregnancy or parent or caretaker relative groups, must be aged 19-26, and must have been receiving SoonerCare as a foster care child when he/she aged out of foster care in Oklahoma. (D) When the LOCEU has made a determination of categorical relationship to disability and SSA later renders a different decision, the Oklahoma Health Care Authority (OHCA) uses the effective date of the SSA approval or denial as their date of disability approval or denial. The procedures outlined in (A) through (G) of this paragraph are applicable when determining categorical relationship based on a SSA disability decision: (A) Already determined eligible for Social Security disability benefits. PHARMACY SERVICES 19 PHYSICIANS AND OTHER PRIMARY CARE PROVIDERS 20 SCHOOL-BASED SERVICES 20 SOONERRIDE (NON-EMERGENCY TRANSPORTATION) SERVICES 21 SoonerCare and American Indians 22 SoonerCare and Our Providers 23 PHYSICIANS AND OTHER PRACTITIONERS 24 LONG-TERM CARE FACILITIES 25 HOSPITALS 26 PHARMACIES 28 OTHER SOONERCARE PROVIDERS … (a) For applications made prior to January 1, 2014, categorical relationship to pregnancy-related services can be established by determining through medical evidence that the individual is currently or has been pregnant. (i) have a long-term medical or physical condition which significantly diminishes his/her functional capacity; (ii) require health-related services that are so inherently complex that it can only be safely and effectively provided by technical or professional medical personnel, such as a registered nurse, licensed practical nurse, etc., and are ordinarily provided in a nursing facility. Such examination is authorized by use of DHS form 08MA016E, Authorization for Examination and Billing. For an individual, your yearly income cannot exceed $24,948 for 2016 – these totals are subject to periodic adjustment. The individual must also provide the expected date of delivery. 0000068317 00000 n Member Portal. • The SC-10 form is located on the public site. accordance with applicable law and regulations. ��3�\F���ǍWb��4���w5AL+Tݾ!F �4� $ܱ�e����1~?�"8/���K��gȑ�)�~�8u�?wqX�! The PCP/CM’s SoonerCare provider number serves as their referral number. The level of care certification period may be for any number of months that the LOCEU determines appropriate. 0000006225 00000 n The DHS worker sends the 08MA016E and DHS form 08MA080E, Report of Physician's Examination, to the physician who will be completing the exam. (c) The level of care determination and cost effectiveness analysis are reported by LOCEU annually. If the effective date of the retroactive disability decision does not cover the period of the medical service because the SSA/SSI application was made subsequent to the service, a medical social summary with pertinent medical information is sent to the LOCEU for a categorical relationship decision for the time period of the medical service. (B) The service(s) needed has been ordered by a physician. John. … www.ok.gov. (b) Effective January 1, 2014, relationship to the pregnancy-related services group under Title XXI is determined in accordance with OAC 317:35-22-1. (1) Determination of categorical relationship to the disabled by Social Security Administration (SSA). The Oklahoma Health Care Authority collects the At the time of application, an assessment form is provided to the applicant for completion by the child's physician. In any instance in which an applicant who was denied SSI on "disability" states the medical condition has worsened since the SSI denial, he/she is referred to the SSA office to reapply for SSI immediately following the filing of the Title XIX application. (B) The effective date (month and year) of eligibility from the standpoint of disability. If the applicant says he/she has never applied for SSI/SSA but appears potentially eligible from the standpoint of unearned income and has an alleged disability which would normally be expected to last for a period of twelve (12) months, he/she is referred to the SSA office to make SSI/SSA application immediately following the filing of the Title XIX application. About Medicaid Expansion; SoonerSelect; Coronavirus Information ; New Out of State Provider Rules for Members; Enroll In SoonerCare; Suspect Medicaid Fraud? Benefits for pregnancies covered under Title XXI medical services are provided within the scope of the program during the prenatal, delivery and postpartum care when included in the global delivery payment. personally identifiable data submitted and received in regard to applications (B) The effective date (month and year) of eligibility from the standpoint of disability. The medical social summary should include relevant social information such as the worker's personal observations, details of the individual's situation including date of onset of the disability, and the reason for the medical decision request. To be eligible for SoonerCare benefits, an individual must be related to one of the following eligibility groups: (5) Children, also including newborns deemed eligible, (8) Breast and Cervical Cancer Treatment program, (10) Benefits for pregnancies covered under Title XXI. The level of care determination is made by LOCEU. h��L�]���+���x�����Y^a�Կ. Title XIX appears in the United States Code as §§1396–1396v, subchapter XIX, chapter 7, Title 42. 28 | O K L A H O M A H E A L T H C A R E A U T H O R I T Y REFERRALS • PCMH initiates all referrals. for services, renewals, appeals, provision of health care and processing of In Oklahoma, the Medicaid program is known as SoonerCare and is operated primarily by the Oklahoma Health Care Authority. Regulations relating to Title XIX are contained in chapter IV, Title 42, and subtitle A, Title 45, Code of Federal Regulations. Example 2: Luz’s spend-down period is from March 1 to August 31.. Luz’s spend-down amount is $500.. By August 20, Luz has $500 in medical bills. "��o��rs��0(c�Y��/F���g0[`�xs���Iw�|zwo����R����� oklahoma state department of health creating a state of … – OK.gov. If the SSI notice shows ineligibility was due to not meeting the disability definition, and the applicant says the medical condition has not worsened since the SSI denial, the Title XIX application is denied for the same reason. 0000003016 00000 n H��Wmo�6��_���P�"E�b1h�b݀nA�}j�A��D�-y��,����D�'-��i;��w��s��W�C��HH�����j�{�d�[�3Ǵ���Uq,��d�2ۑ2����7��˜J�dLS$`MHi����'��x��&$�l^�0%��~�l���MEX���MI����������Enʫ�4d���g���D�@R-$����_��]�7%y���mQ�f�� >0AY���2�4�O��xO��8�M��IL"�Єi�< N��]i��Ͽ?1J��ه�:��0"��M�Ͻ��( However, there are different income limits for different plans and categories. identifiable data with its authorized business associates, government agencies PREFACE. SoonerCare Choice Reimbursement Tiers: Tier 1: $3.46 to $4.85 PMPM range. Medical information submitted might include physical exam results, psychiatric, lab, and x-ray reports, hospital admission and discharge summaries, and/or doctors' notes and statements. 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