Policy 317:35-19-19

Skilled care can be provided in a nursing facility and/or hospital if they have the staff and services, and are licensed, to provide the skilled care. Care that can be provided by non-professional staff is not considered to be skilled care.

Only Persons enrolled in Medicare Part A are eligible for payment for skilled care.

Medicare Part A pays 100% of the first 20 days of skilled care. Medicare pays 80% of skilled care for days 21 through 100. It is only necessary to process an application if the individual remains in skilled care longer than 20 days so OHCA can pay the 20% coinsurance for the days exceeding 20.

When an individual, who is enrolled in Medicare Part A, is already receiving SoonerCare through the QMB Plus program, no additional action is needed as the 20% coinsurance will be paid through the SoonerCare benefit. The QMB Plus income standard is found on Appendix C-1, Schedule VI.

QMB Plus income eligible individuals are allowed the resource standard as shown on Appendix C-1, Schedule VI, but must meet the SoonerCare resource standard as shown on Appendix C-1, Schedule VIII.D, for NF level of care (ICF care).

Determining Eligibility for Skilled Nursing Care

Income Standards

• If an individual is out of the home less than 30 days, the individual must meet QMB Plus income standards (Appendix C-1, Schedule VI) to be eligible for skilled care for days 21 through 30.
• Beginning day 31 out of the home, the client must meet the categorically needy LTC income (Appendix C-1, Schedule VIII.B) limit to be eligible for skilled care for day 31 forward.
• If the client’s income is over the categorically needy LTC income standard (Appendix C-1, Schedule VIII.B.1), a MIPT can be established to become eligible beginning on Day 31. The MIPT must be both set up and funded by the 31^st day in skilled care in order for the person to be eligible beginning on the 31^st day of skilled care.

Resource Standards

• If the client’s income is under the QMB Plus income standard (Appendix C-1, Schedule VI) then the resource standard shown in Appendix C-1, Schedule VI is used to determine the client’s eligibility.
• If the client’s income is over the QMB Plus income standard, the resource standard shown on Appendix C-1, Schedule VIII.D is used to determine the client’s eligibility. If the client is married, the minimum resource standard shown on Appendix C-1, Schedule XI is used for the Community Spouse. Total resources for the married couple cannot exceed Appendix C-1, Schedule VIII.D PLUS Appendix C-1, Schedule XI.

Additional Eligibility Information

• There is no need to put an authorization on for skilled care.
• If the client is transferred from SNF to ICF, an authorization must be added once determined ICF eligible.
• No split/spenddown is done on resources for a couple prior to ICF entry.
• Transfer of assets rules do not apply to skilled care.