AFS Policy: Medicaid

Medicaid – is a health insurance program jointly funded by the state and federal governments but managed by the states.   This term is used throughout SoonerCare (Medicaid) policy.

  • Chapter 35. Medical Assistance for Adults and Children – Eligibility:
  • Coverage and Exclusions:
  • Eligibility and Countable Income:
    • 317:35-5-1. Scope and applicability
    • 317:35-5-2. Categorically related programs
    • 317:35-5-3. Determining categorical relationship to the aged
    • 317:35-5-4. Determining categorical relationship to the disabled
    • 317:35-5-4.1. Special level of care and cost effectiveness application procedures for TEFRA
    • 317:35-5-5. Determining categorical relationship to the blind
    • 317:35-5-6. Determining categorical relationship to pregnancy-related services
    • 317:35-5-6.1 Determining categorical relationship for pregnancy related services under Title XXI
    • 317:35-5-7. Determining categorical relationship to the children and parent and caretaker relative groups
    • 317:35-5-8. Determining categorical relationship for the SoonerPlan Family Planning Program
    • 317:35-5-9. Determining categorical relationship to expansion adults;
    • 317:35-5-25. Citizenship/alien status and identity verification requirements
    • 317:35-5-26. Residence requirements; residents of public institutions; homeless persons; and residents of HIS, BIA, or Tribal controlled dormitories
    • 317:35-5-27. Social Security number
    • 317:35-5-40. Scope and applicability
    • 317:35-5-41. Determination of capital resources for individuals categorically related to aged, blind and disabled
    • 317:35-5-41.1. Home/real property;
    • 317:35-5-41.2. Miscellaneous Personal property
    • 317:35-5-41.3. Automobiles, pickups, and trucks
    • 317:35-5-41.4. Stocks and bonds
    • 317:35-5-41.5. Purchases of promissory notes, loans, or mortgages
    • 317:35-5-41.6. Trust accounts
    • 317:35-5-41.7. Retirement funds
    • 317:35-5-41.8. Eligibility regarding long-term care services
    • 317:35-5-41.9. Resource disregards
    • 317:35-5-41.10. Changes in capital resources
    • 317:35-5-41.11. Maximum Resources
    • 317:35-5-41.12. Real or personal property essential to self-support;
    • 317:35-5-42. Determination of countable income for individuals categorically related to aged, blind and disabled
    • 317:35-5-43. Third party resources; insurance, workers’ compensation and Medicare
    • 317:35-5-44. Child/spousal support
    • 317:35-5-45. Determination of income and resources for children and parents and caretaker relatives
    • 317:35-5-46. Determination of income and resources for categorical relationship to pregnancy-related services
    • 317:35-5-47. Determination of income and resources for categorical relationship to Disability for TB infected individuals
    • 317:35-5-48 Determination of income and resources for categorical relationship to expansion adults;
    • 317:35-5-49. Determination of income and resources for categorical relationship to TEFRA
    • 317:35-5-60. Application for SoonerCare; forms
    • 317:35-5-63. Agency responsible for determination of eligibility
    • 317:35-5-64. Cooperation in determination of eligibility
    • 317:35-5-65. Notification of eligibility;
    • 317:35-5-66. Electronic Notices;
    • 317:35-5-67. Returned mail;
  • SoonerCare Health Benefits for Categorically Needy Pregnancy Women and Families with Children:
    • 317:35-6-1. Scope and applicability
    • 317:35-6-15. SoonerCare application for pregnant women, families with children, and expansion adults; forms
    • 317:35-6-35. General eligibility consideration
    • 317:35-6-36. Financial eligibility of individuals categorically related to AFDC or pregnancy-related services or expansion adults;
    • 317:35-6-37. Financial eligibility of categorically needy individuals related to AFDC or pregnancy-related services parent/caretaker relatives, families with children, and expansion adults
    • 317:35-6-38. Hospital Presumptive Eligibility
    • 317:35-6-39. General calculation of countable income for MAGI eligibility groups
    • 317:35-6-40. MAGI household composition; taxpayers and tax dependents
    • 317:35-6-41. MAGI household composition; tax filers
    • 317:35-6-42. MAGI household composition; exceptions to tax filer rules
    • 317:35-6-43. MAGI household composition; non-filers
    • 317:35-6-44. Determination of whether a household member’s income is counted
    • 317:35-6-50. Countable sources of income
    • 317:35-6-51. Exceptions to Internal Revenue Code rules
    • 317:35-6-52. Adjustments to income
    • 317:35-6-53. Determination of current monthly income
    • 317:35-6-55. Treatment of qualified lottery or qualified gambling winnings;
    • 317:35-6-60. Certification for SoonerCare for pregnant women and families with children
    • 317:35-6-60.1. Changes in circumstances
    • 317:35-6-60.2. Retroactive eligibility;
    • 317:35-6-61. Redetermination of eligibility for persons receiving SoonerCare
    • 317:35-6-63. Denials
    • 317:35-6-64. Closures
    • 317:35-6-64.1. Transitional Medical Assistance (TMA)
    • 317:35-6-65. Transfer of case records between counties
  • Medical Services:
    • 317:35-7-1. Scope and applicability
    • 317:35-7-16. Special application procedure for children in OKDHS custody
    • 317:35-7-36. Financial eligibility of individuals categorically related to ABD
    • 317:35-7-38. Financial eligibility of categorically needy individuals related to ABD
    • 317:35-7-40. Eligibility as Qualified Medicare Beneficiary Plus
    • 317:35-7-41. Eligibility as Qualified Disabled and Working Individual
    • 317:35-7-43. Eligibility as Specified Low-Income Medicare Beneficiaries
    • 317:35-7-44. Eligibility for TB related services
    • 317:35-7-46. Eligibility as Qualifying Individuals
    • 317:35-7-48. Eligibility for the SoonerPlan Family Planning Program
    • 317:35-7-60. Certification for SoonerCare
    • 317:35-7-60.1. Certification for the SoonerPlan Family Program
    • 317:35-7-61. Redetermination of eligibility for persons receiving ABD or TANF
    • 317:35-7-61.1. Special redetermination procedures for TEFRA
    • 317:35-7-62. Special redetermination procedures for children in custody or subsidized adoptions
  • ICF/MR, HCBW/MR, and Individuals Age 65 or Older in Mental Health Hospitals:
    • 317:35-9-1. Overview of long-term medical care services; relationship to QMB, SLMB, and other Medicaid services eligibility, and spenddown calculation
    • 317:35-9-4. Services in Intermediate Care Facility for Individuals with Intellectual Disabilities (public and private)
    • 317:35-9-5. Home and Community – Based Services (HCBS) Waivers for persons with intellectual disabilities or certain persons with related conditions
    • 317:35-9-7. Services for persons age 65 or older in mental health hospitals
    • 317:35-9-15. Medicaid recovery
    • 317:35-9-25. Application for ICF/MR, HCBW/ID, and persons aged 65 or over in mental health hospitals
    • 317:35-9-26. Application procedures for private ICF/MR
    • 317:35-9-27. Application procedures for public ICF/MR
    • 317:35-9-28. Application procedures for services provided by Developmental Disability Services Division (DDSD)
    • 317:35-9-29. Application procedures for persons age 65 or older in mental health hospitals
    • 317:35-9-45. Determination of medical eligibility for care in a private Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)
    • 317:35-9-48. Determination of medical eligibility for care in public ICF/MR
    • 317:35-9-48.1. Determining ICF/IID institutional level of care for TEFRA children
    • 317:35-9-49. Determination of medical eligibility for Home and Community Based Waiver Services for the Intellectually Disabled
    • 317:35-9-50. Determination of medical eligibility for persons age 65 or older in mental health hospitals
    • 317:35-9-65. General financial eligibility requirements for ICF/MR, HCBW/MR and individuals age 65 or older in mental health hospitals
    • 317:35-9-67. Determination financial eligibility of categorically needy individuals
    • 317:35-9-68. Determining financial eligibility for care in an ICF/MR (public and private), for HCBW/MR services, and for persons age 65 or older in mental health hospitals
    • 317:35-9-75. Certification for long-term medical care through ICF/IID, HCBW/IID services and to persons age 65 and older in a mental health hospital
    • 317:35-9-76. Redetermination of financial eligibility for long-term medical care
    • 317:35-9-77. Case transfer between categories
    • 317:35-9-78. Case changes
    • 317:35-9-95. Payment to ICF/MR (public and private)
    • 317:35-9-97. Payment for Home and Community Based Waiver services for the Intellectually Disabled (HCBW/ID)
    • 317:35-9-98. Payment to mental health hospitals
    • 317:35-9-99. Billing procedures for ICF/MR, HCBW/MR services and services for individuals 65 or older in a mental health hospital
    • 317:35-9-100. Management of client’s funds while receiving care in NF,ICF/MR (public and private) or for persons age 65 or older in mental health hospitals
    • 317:35-9-101. Disclosure of information of health care providers and contractors
    • 317:35-9-102. Referral for social services
    • 317:35-9-103. Special procedures for release of adults in mental health hospitals to long-term care facilities
  • Medical Aid to Families with Dependent Children:
  • Projects:
  • Client Rights and Responsibilities:
  • Personal Care Services:
    • 317:35-15-1. Overview of long-term medical care services; relationship to QMBP, SLMB and other SoonerCare services and eligibility
    • 317:35-15-2. Personal Care services
    • 317:35-15-3. Application for Personal Care
    • 317:35-15-4. Determination of medical eligibility for Personal Care
    • 317:35-15-5. General financial eligibility requirements for Personal Care
    • 317:35-15-6. Determining financial eligibility of categorically needy individuals
    • 317:35-15-7. Certification for Personal Care
    • 317:35-15-8. Agency Personal Care Service Authorization and Monitoring
    • 317:35-15-8.1. Agency Personal Care services; billing; and issue resolution
    • 317:35-15-9. Redetermination of financial eligibility for Personal Care
    • 317:35-15-10. Redetermination of medical eligibility for Personal Care services
    • 317:35-15-12. Case changes
    • 317:35-15-13.1. Individual Personal Care service management
    • 317:35-15-13.2. Individual Personal Care contractor; billing, training, and problem resolution
    • 317:35-15-14. Billing procedures for Personal Care
    • 317:35-15-15. Referral for social services
  • ADvantage Waiver Services:
    • 317:35-17-1. Overview of long-term medical services; relationship to QMBP, SLMB and other Medicaid services eligibility
    • 317:35-17-2. Level of care medical eligibility determination
    • 317:35-17-3. ADvantage program services
    • 317:35-17-4. Application for ADvantage services
    • 317:35-17-5. ADvantage program medical eligibility determination
    • 317:35-17-9. General financial eligibility requirements for the ADvantage program
    • 317:35-17-10. Determining financial eligibility/categorical relationship for the ADvantage program
    • 317:35-17-11. Determining financial eligibility for ADvantage program services
    • 317:35-17-12. Certification for ADvantage program services
    • 317:35-17-14. Case Management services
    • 317:35-17-15. Redetermination of eligibility for ADvantage services
    • 317:35-17-16. Member annual level of care re-evaluation and annual re-authorization of service plan
    • 317:35-17-18. ADvantage services during hospitalization or NF placement
    • 317:35-17-19. Closure or termination of ADvantage services
    • 317:35-17-21. Case changes
    • 317:35-17-21.1. ADvantage and agency Personal Care provider certification
    • 317:35-17-22. Billing procedures for ADvantage services
    • 317:35-17-23. Disclosure of information of health care providers and contractors
    • 317:35-17-24. Referral for social services
    • 317:25-17-25. Address Confidentiality Program 
  • Programs of All-Inclusive Care for the Elderly (PACE):
  • Nursing Facility Services:
  • Breast and Cervical Cancer Treatment Program:
  • Pregnancy Related Benefits Covered under Title XXI:
  • Living Choice Program:
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