(a)
Financial
eligibility for NF care. Financial eligibility for NF care is determined
using the rules on income and resources according to the eligibility group to
which the individual is related.
(1) Income,
resources and expenses are evaluated on a monthly basis for all individuals
requesting payment for NF care. Each individual requesting payment for NF care
is allowed a personal needs allowance.
(2) To be eligible for long-term care in an
NF, the individual must be determined categorically needy according to the
standards appropriate to the categorical relationship.
(3) If the individual's gross income exceeds
the categorically needy standard as shown on OKDHS Appendix C-1, 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 spenddown amount is determined based on type of care,
categorical relationship, community spouse, etc.
(5) The spenddown is applied to the vendor
payment on the first NF claim(s) received on behalf of the
individual.
(6) For an individual
eligible for long-term care in a NF, the individual's share of the vendor
payment is not prorated over the month. As SoonerCare is the payer of last
resort, the full amount of the member's share of the vendor payment must first
be applied to the facility's charges before SoonerCare reimbursement
begins.
(b)
Financial eligibility for skilled nursing. Skilled Nursing Care is
covered as part of the Medicare Part A coverage. For members who are currently
receiving this benefit through the QMB program, no further action is needed.
For individuals who do not have an active SoonerCare case, an application is
processed to receive the Medicare crossover and deductible benefits. Income
eligibility is based on the categorically needy standard in OKDHS Appendix C-1,
Schedule VI., for the first 30 days. After the initial 30 days, income
eligibility is based on the categorically needy standard in OKDHS Appendix C-1,
Schedule VIII. B. 1.
(1) QMB eligible
individuals in skilled nursing care are allowed the resource standard as shown
on OKDHS Appendix C-1, Schedule VI, but must meet the SoonerCare resource
standard as shown on OKDHS Appendix C-1, Schedule VIII. D., for NF level of
care. For individuals with no active case, use the resource standard shown on
OKDHS Appendix C-1, Schedule VIII. D.
(2) Rules concerning transfer of assets do
not apply to skilled level of care.
