(a) Application . An application for pregnant women, families with children, and expansion adults consists of the SoonerCare application. The application form is signed by the individual, parent, spouse, guardian, or someone else acting on the individual's behalf. An individual does not have to have received a medical service nor expect to receive one to be certified for SoonerCare. Individuals who wish to use a paper application form to apply for coverage under a Modified Adjusted Gross Income (MAGI) eligibility group must submit the federal Single Streamlined Application to apply for SoonerCare. (1) An application may be made in a variety of locations, for example, a physician's office, a hospital or other medical facility, Oklahoma Department of Health, in the individual's county Oklahoma Department of Human Services (OKDHS) office, or online. A face-to-face interview is not required. Applications are mailed to the Oklahoma Health Care Authority (OHCA) Eligibility Unit. When an individual indicates a need for SoonerCare, the physician or facility may forward an application to the OHCA Eligibility Unit for processing. If the applicant is unable to sign the application, someone acting on his/her behalf may sign the application. An application for SoonerCare may also be submitted through the Health Insurance Exchange. (2) OKDHS form 08MA005E, Notification of Needed Medical Services, is required only for preauthorization of medical services. Although not required, the form may be submitted by the physician or facility as notification of a need for medical services. The form also may be accepted as medical verification of pregnancy. (3) Receipt of the SoonerCare application form or OKDHS form 08MA005E constitutes an application for SoonerCare. (4) If OKDHS form 08MA005E is received and a SoonerCare application cannot be completed, receipt of OKDHS form 08MA005E constitutes an application which must be registered and subsequently denied. The applicant and provider are notified by computer-generated notice. (5) A hospital providing services may file an electronic Notification of Date of Service (NODOS) form with OHCA up to five (5) days from the date services are rendered. The hospital, applicant, or someone acting on the applicant's behalf has forty (40) days from the date the NODOS form was received by OHCA to submit a completed SoonerCare application. Filing a NODOS does not guarantee coverage and if a completed application is not submitted within forty (40) days, the NODOS is void. (b) Date of application . When an application is made online, the date of application is the date the application is submitted online. The date of application for a paper application is the date a signed application is received and stamped in by contracted agency partners or OHCA. When a request for SoonerCare is made orally, and that request is followed within twenty (20) days by a signed application, the documented date of the oral request is the date of application. When OKDHS form 08MA005E is received by OKDHS, or received by OHCA and forwarded to OKDHS, the earliest of the date stamps is considered the date of request and should be honored when followed within twenty (20) days by a signed application for SoonerCare. (c) Other application and signature requirements. For additional rules regarding other application and eligibility determination procedures, see Part 7 of Subchapter 5 of this Chapter.

(a) Prior to October 1, 2013. Financial eligibility for SoonerCare Health Benefits for Pregnant Women and Families with Children is determined using the rules on income according to the category to which the individual is related. (See Part 5, Subchapter 5 of this Chapter.) Unless questionable, the income of categorically needy individuals who are categorically related to AFDC does not require verification. There is not a resource test for individuals categorically related to AFDC or pregnancy related services. (b) Effective October 1, 2013. Financial eligibility for SoonerCare Health Benefits for MAGI eligibility groups is determined using the MAGI methodology. Unless questionable, the income of individuals who are related to a MAGI eligibility group does not require verification. There is no resource test for individuals related to any of the MAGI groups (see Part 1 of this Subchapter for a list of the MAGI groups). (c) When medical assistance is requested on behalf of any individual, eligibility is determined for that individual as well as all other individuals in the family unit who meet basic criteria for a SoonerCare eligibility group. (d) Income is evaluated on a monthly basis for all individuals included in the case for Health Benefits.

(a) When determining financial eligibility for an individual related to AFDC, pregnancy-related services or expansion adults, the income of the following persons (if living together or if living apart as long as there has been no break in the family relationship) are considered. These persons include the: (1) Individual; (2) Spouse of the individual; (3) Biological or adoptive parent(s) of the individual who is a minor dependent child. For health benefits only, income of the stepparent of the minor dependent child is determined according to OAC 317:35-5-45; (4) Minor dependent children of the individual if the children are being included in the case for health benefits. If the individual is nineteen (19) years or older and not pregnant, at least one (1) minor dependent child must be living in the home and included in the case for the individual to be related to AFDC; (5) Blood related siblings, of the individual who is a minor child, if they are included in the case for health benefits; or (6) Caretaker relative and spouse (if any) and minor dependent children when the caretaker relative is to be included for coverage. (b) The MAGI methodology is used to determine eligibility for MAGI eligibility groups. See OAC 317:35-6-39 through 317:35-6-54. (c) Individuals who are determined to be part of a MAGI household cannot be excluded from the household; likewise, income of individuals determined to be part of a MAGI household cannot be excluded unless the exclusion is expressly required under MAGI rules.

Individuals whose income is less than the SoonerCare income guidelines for the applicable eligibility group are financially eligible for SoonerCare. (1) Categorically related to pregnancy-related services. For an individual related to pregnancy-related services to be financially eligible, the countable income must be less than the appropriate standard according to the family size on the SoonerCare income guidelines. In determining the household size, the pregnant woman and her unborn child(ren) are included. (2) Categorically related to the children and parent/caretaker relative groups. (A) Parent/caretaker relative group. For the individual in the parent/caretaker relative group to be considered categorically needy, the SoonerCare income guidelines must be used. (i) Individuals age nineteen (19) years or older, other than pregnant women, are determined categorically needy if countable income is equal to or less than the categorically needy standard, according to the family size. (ii) All individuals under nineteen (19) years of age are determined categorically needy if countable income is equal to or less than the categorically needy standard, according to the size of the family. (B) Families with children. Individuals in the children or parent/caretaker relative groups are eligible if they meet applicable MAGI-based income standards and all other Medicaid eligibility requirements. (3) Expansion adults. Individuals who meet financial eligibility criteria for expansion adults are established and defined by 42 C.F.R. § 435.119 and by the Oklahoma Medicaid State Plan.

(a) General. HPE is a limited period of SoonerCare eligibility for individuals who are categorically related to certain Modified Adjusted Gross Income (MAGI) eligibility groups listed in OAC 317:35-6-38(a)(1)(A)(i) through (vi) and are also determined by a qualified hospital [see OAC 317:35-6-38(a)(2)(A) through (L) for the conditions of a qualified hospital], on the basis of preliminary information provided by the applicant on a completed HPE application, to be eligible for SoonerCare services. The rules in this Section apply only to those individuals applying for, or qualified hospitals determining eligibility under, the HPE program. (1) Individuals eligible to participate in the HPE program. To be eligible to participate in the HPE program, an individual must be categorically related to a MAGI eligibility group (see OAC 317:35-5-2 for categorical relationship criteria) and also meet the income standard and non-medical eligibility specified in this Section. (A) MAGI eligibility groups. The following MAGI eligibility groups are eligible to have a presumptive eligibility (PE) determination made by a qualified hospital participating in the HPE program: (i) Children; (ii) Pregnant women; (iii) Parent/caretaker relatives; (iv) Expansion adults; (v) Former foster care children; (vi) Breast and Cervical Cancer (BCC) treatment program; and (vii) SoonerPlan family planning program. (B) Income standard. The income that is counted in determining PE for an individual is that individual's household income. The income limit for the MAGI eligibility groups covered under the HPE program is the same as defined in OAC 317:35-6-39(b)(8) and is listed on the HPE application. The calculation of countable household income for an individual covered under the HPE program is the same as OAC 317:35-6-39, except that, in determining the individual's household composition, only the MAGI household composition non-filer rules listed under OAC 317:35-6-43 apply for all individuals applying for the HPE program regardless of whether or not the individual is a tax filer, plans on filing taxes, or is a tax dependent. (C) Non-medical eligibility requirements. Individuals covered under the HPE program must also meet the non-medical eligibility requirements described in OAC 317:35-5-25. (D) Pregnant women covered under the HPE program. Coverage for pregnant women who are covered under the HPE program is limited to ambulatory prenatal care only, and the number of PE periods that may be authorized for pregnant women is one (1) per pregnancy. Pregnant women who may be covered for the benefit of the unborn child(ren) under Title XXI are not eligible for the HPE program. (E) Other individuals covered under the HPE program. Coverage for other individuals listed under OAC 317:35-6-38(a)(1)(A)(i) through (vi) who are covered under the HPE program, except for pregnant women, is the same as covered under the State Plan. The number of PE periods that may be authorized is one (1) period every three hundred sixty-five (365) days beginning on the date the individual is enrolled in HPE. (2) Qualified hospital. The decision that a hospital is qualified to make PE determinations is made by the Oklahoma Health Care Authority. In order to participate in the HPE program and make PE determinations, a qualified hospital must: (A) Meet all the conditions of an eligible provider under OAC 317:30-5-40; (B) Elect to participate in the HPE program by: (i) Completing and submitting a HPE Statement of Intent and Memorandum of Understanding to the OHCA and agreeing to all the terms and conditions of the HPE program; (ii) Amending its current contract with the OHCA to include participation in the HPE program; (C) Assign and designate a hospital employee to serve as the HPE program administrator and point of contact; (D) Assign and designate hospital employees to make PE determinations. The term "authorized hospital employee(s) (AHE)" means all individuals making PE determinations on behalf of a hospital participating in the HPE program. The AHE must meet the following conditions: (i) Be an employee of the hospital (i.e. the AHE may not be a third party contractor); (ii) Attend, complete, and pass the HPE program training course provided and assessed by the OHCA; (iii) The AHE certificate of HPE course completion must be kept in the worker's file at the hospital and must be made available to the OHCA upon request; (iv) Follow state and federal privacy and security requirements regarding patient confidentiality; (v) Agree to abide by all the rules and guidelines of the HPE program established by the OHCA under this Section. (E) Notify the OHCA of any changes in the AHE's employment status or in the designation of that individual as the hospital's AHE; (F) Abide by the rules and regulations of the Uniform Electronic Transaction Act as outlined in OAC 317:30-3-4.1; (G) Keep internal records of all individuals for whom a PE determination was made and make those records available to the OHCA upon request; (H) Agree to submit all completed HPE applications and PE determinations to the OHCA within five (5) days of the PE determination; (I) Notify the applicant in writing, or in cases where the HPE application was made on behalf of a child, notify the child's parent or caretaker of the PE determination outcome and provide and explain to eligible members the "HPE Program Policy and Enrollment" form; (J) Assist HPE applicants with the completion of a full SoonerCare application within fifteen (15) days of the HPE application submission to the OHCA; (K) Agree to adhere to the processes and procedures established by the OHCA regarding the operation and oversight of the HPE program; and (L) Cooperate with the OHCA regarding audit and quality control reviews on PE determinations the hospital makes. The agency may terminate the HPE agreement with the hospital if the hospital does not meet the standards and quality requirements set by the OHCA. (3) Limited hospital PE determinations. The agency limits the PE determinations that a hospital may make to only those eligibility groups described in OAC 317:35-6-38(a)(1)(A) using the MAGI methodology rules established for the HPE program. Additionally, PE determinations made for individuals categorically related to the Breast and Cervical Cancer (BCC) treatment program are limited to qualified hospitals that are also qualified entities through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). (b) General provisions of the HPE program. The agency provides SoonerCare coverage to eligible individuals covered during a period of PE. (1) PE period. The PE period begins on the date a qualified hospital determines an individual to be eligible under the HPE program. A qualified hospital has five (5) days to notify the agency of its PE determination. The PE period ends with the earlier of: (A) The day the agency receives the SoonerCare application form as described in OAC 317:35-5-60 and an eligibility determination is made by the agency; or (B) If a SoonerCare application is not received, the last day of the month following the month in which the PE determination was made. (2) Agency approval of PE. When the OHCA receives a timely and completed HPE application, a case number and, if needed, SoonerCare member ID is assigned to the member by the agency. Qualified hospitals will be able to review member enrollment and eligibility, once those members have been entered into the system by the OHCA, for claims billing and member eligibility verification. (3) Incomplete HPE applications. Upon receiving a HPE application, the OHCA reviews it for completeness and correctness. The HPE application is considered incomplete if it is not filled out in its entirety (e.g., the applicant's first or last name is not provided on the application) or if the application is not filed timely with the OHCA. When the HPE application is determined to be incomplete, the HPE application is returned to the AHE or the HPE program administrator at the qualified hospital to correct the application errors or amend the HPE application. To maintain the original PE certification period, the qualified hospital must return the completed or corrected HPE application to the agency within five (5) working days. (4) Applicant appeal. The HPE applicant cannot appeal the PE determination made by a qualified hospital or the expiration date of the PE period. (5) Applicant ineligibility. Applicants ineligible for the HPE program are individuals who do not meet the HPE criteria, individuals who have previously been enrolled in the HPE program within the last three hundred sixty-five (365) days, and individuals currently enrolled in SoonerCare. Individuals currently enrolled in SoonerPlan family planning are not eligible for HPE family planning services, but may be eligible for other programs under HPE. When the OHCA receives a HPE application from a qualified hospital for an ineligible applicant [e.g., the applicant has been previously enrolled in the HPE program within the last three hundred sixty-five (365) days], the OHCA will disenroll the individual from the HPE program immediately and notify the hospital of the error. The hospital will be responsible for following up with that individual to notify them of their disenrollment from the HPE program. If the applicant is not currently enrolled into SoonerCare, the applicant may submit a full SoonerCare application and receive a full eligibility determination by the OHCA. HPE services provided to ineligible applicants, other than persons currently enrolled into SoonerCare or SoonerPlan family planning program, may not be eligible for reimbursement by the OHCA.

(a) The income that is counted in determining eligibility for an individual is that individual's household income. (b) In order to calculate the countable household income for an individual: (1) Determine who is in the individual's household (see OAC 317:35-6-40 to 317:35-6-43); (2) Identify all sources of income for all household members; (3) Determine whether each source of income is considered for SoonerCare eligibility or is excluded (see Part 6, Countable Income, of this Subchapter); (4) Determine the gross monthly amount of each source of countable income (see Part 6, Countable Income, of this subchapter); (5) Determine whether each household member's income counts toward the household (see 317:35-6-44); (6) Sum the gross monthly amounts of all countable sources of income of all household members whose income is counted; (7) Subtract allowable adjustments to income (see OAC 317:35-6-52); and (8) Compare the result to the income limit for the individual's eligibility group (see SoonerCare Income Guidelines). If the result is equal to or less than the dollar amount of the income limit, the individual is financially eligible. (9) When calculating the percentage of the Federal Poverty Level (FPL) that corresponds to the individual's monthly countable income, subtract 5% from the FPL percentage reached to determine the countable FPL level for the individual. This countable percentage of FPL is compared to the FPL limit for the individual's eligibility group in order to determine whether the individual is financially eligible. This 5% deduction from FPL has already been accounted for in the dollar amounts of the income limits given in the SoonerCare Income Guidelines. (c) If an individual's household income using this methodology is over the income limit for SoonerCare eligibility and that individual's household income using the MAGI household and income-counting methodology used by the Federally Facilitated Exchange (FFE) is less than 100% of FPL, the FFE's MAGI rules, as promulgated by the Internal Revenue Service, are used to determine SoonerCare eligibility in place of the rules in this Chapter. The FFE rules including, but not limited to, those in the following areas may need to be followed in place of the SoonerCare rules in this Chapter: (1) Rules on household composition; (2) Rules on countable sources of income; and (3) Rules on the budget period used to calculate income, i.e. annual income (FFE) versus current monthly income (SoonerCare).

(a) The rules used to determine MAGI household composition depend on tax relationships. (b) Whether an individual is a taxpayer or a tax dependent at the time of application is determined by whether the applicant expects to file taxes or expects to be claimed as a tax dependent by another taxpayer for the current tax year in which the determination of eligibility for SoonerCare is made.

(a) Scope. This section applies to individuals who expect to file taxes themselves or who expect to be claimed by another taxpayer as a tax dependent for the taxable year in which the eligibility determination is being made. (b) Taxpayers. The household of an individual who expects to be a taxpayer consists of him or herself and all of the tax dependents he or she expects to claim. (c) Tax dependents. If an individual expects to be both a taxpayer and a tax dependent, the individual is considered a tax dependent. Unless an exception listed in OAC 317:35-6-42 applies, the household of an individual who expects to be claimed as a tax dependent consists of the taxpayer claiming him or her and all other dependents expected to be claimed by that taxpayer. (d) Spouses. Spouses who live together are always counted in each other's households, regardless of whether or how they expect to file taxes, and regardless of whether one or both of them expect to be claimed as a tax dependent by another taxpayer. (e) Unborn children. If any member of the household is pregnant, the number of children she expects to deliver is counted in the household size of all households of which she is a member. (f) No option to exclude. Individuals may not choose to exclude any person counted as a household member under this rule from the household.

(a) The tax filer household composition rules in OAC 317:35-6-41 do not apply to the following individuals: (1) Individuals who expect to be claimed as a tax dependent by a taxpayer who is not their spouse or biological, adoptive, or step parent, regardless of the individual's age; (2) Individuals under the age of 19 who are living with two parents, whose parents do not expect to file a joint return, and who expect to be claimed as a dependent by one of their parents; or (3) Individuals under the age of 19 who expect to be claimed as a tax dependent by a non-custodial parent. (b) The non-filer household composition rules in OAC 317:35-6-43 apply to individuals who are claimed as tax dependents but are described in one of the exceptions to the tax filer rules in (a). (c) If an individual's declaration that another person is a tax dependent is not reasonably compatible with other information available to OHCA, the non-filer household composition rules are used to determine whether the person will be included in the household of the taxpayer.

(a) The household composition defined in this section applies to individuals who do not expect to file taxes and do not expect to be claimed as a tax dependent by another taxpayer for the taxable year during which eligibility is being determined. This section also applies to individuals described in an exception to the tax filer household in OAC 317:35-6-42. (b) The non-filer household consists of the individual, and if applicable and if living with the individual: (1) the individual's spouse; (2) the individual's natural, adopted and step children under the age of 19; (3) if the individual is under the age of 19, the individual's natural, adoptive and step parents; and (4) if the individual is under the age of 19, the individual's natural, adoptive and step siblings who are also under the age of 19. (c) If any member of the household is pregnant, the number of children she expects to deliver is counted in the household size of all households of which she is a member. (d) Individuals may not choose to exclude any person counted as a household member under this rule from the household.

(a) Unless a household member falls into an exception listed in this Section, his or her income counts for him or herself and for all members of all households of which the individual is a member. (b) The income of the following individuals is not included in household income of the household to which the exception applies: (1) Individuals included in a household of which their biological, adoptive or step parent(s) is/are also member(s), who are not expected to be required to file a tax return for the tax year during which eligibility is being determined (regardless of whether the individual later does in fact file a tax return, and regardless of the individual's age); and (2) Individuals claimed as tax dependents by someone other than their spouse or biological, adoptive or step parent who are not expected to be required to file a tax return for the tax year during which eligibility is being determined (regardless of whether the individual does in fact file a tax return, and regardless of the individual's age). (c) If an individual's income is excluded from the household of a parent or of the taxpayer claiming him or her as a dependent because one of the exceptions in paragraph (b) of this section applies, the individual's income is still included in other households of which the individual is also a member, provided no exceptions listed in this section apply to those households. (d) See 317:35-10-38 for rules regarding temporary absence from the home.

(a) The Oklahoma Health Care Authority (OHCA) shall receive applications from and make eligibility determinations for individuals residing in correctional institutions, including juvenile facilities. However, the SoonerCare program will only pay for services rendered to individuals residing in a correctional institution as specified in Oklahoma Administrative Code (OAC) 317:35-5-26. (b) In accordance with federal law, including, but not limited to, 42 United States Code (U.S.C.) § 1396a(a)(84), individuals residing in correctional institutions who are under the age of twenty-one (21) or who meet the former foster care child requirements found at OAC 317:35-5-2, shall have their eligibility suspended for the duration of the incarceration period, except for periods of time that inpatient services are provided as specified in OAC 317:35-5-26. (c) The effective date of the suspension is the calendar day following the date on which an individual described in (b) of this section becomes incarcerated. (d) A redetermination of eligibility for an individual described in (b) of this section shall be conducted prior to release to determine if the individual continues to meet the eligibility requirements for SoonerCare. A new application will not be required to redetermine eligibility. (e) Suspended eligibility shall be restored to the release date after a redetermination of eligibility, when: (1) The Oklahoma Department of Human Services (OKDHS), using the release date supplied by the Oklahoma Office of Juvenile Affairs (OJA) or the Oklahoma Department of Corrections (DOC), removes the suspension; (2) The individual reports his or her release to the Oklahoma Health Care Authority (OHCA) within ten (10) calendar days of the release date; or (3) The individual reports his or her release to OHCA more than ten (10) calendar days from the release date, and there is good cause for the delay in reporting.

Unless an exception listed in OAC 317:35-6-51 applies, all income included in Modified Adjusted Gross Income in Section 36B of the Internal Revenue Code is included in the MAGI calculation for SoonerCare eligibility.

(a) The following sources of income are excluded from household income for SoonerCare eligibility under Modified Adjusted Gross Income (MAGI), regardless of whether they are included in MAGI in Section 36B of the Internal Revenue Code: (1) Scholarships, awards, or fellowship grants used for education purposes and not for living expenses; and (2) The following types of American Indian / Alaska Native income: (A) Distributions from any property held in trust, subject to Federal restrictions, located within the most recent boundaries of a prior Federal reservation, or otherwise under the supervision of the Secretary of the Interior; (B) Distributions and payments from rents, leases, rights of way, royalties, usage rights, or natural resource extraction and harvest from: (i) Rights of ownership or possession in any lands described in Paragraph (a)(2)(A) of this section; or (ii) Federally protected rights regarding off-reservation hunting, fishing, gathering, or usage of natural resources; (C) Distributions resulting from real property ownership interests related to natural resources and improvements: (i) Located on or near a reservation or within the most recent boundaries of a prior Federal reservation; or (ii) Resulting from the exercise of federally-protected rights relating to such real property ownership interests; (D) Payments resulting from ownership interests in or usage rights to items that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable Tribal Law or custom; (E) Student financial assistance provided under the Bureau of Indian Affairs education programs; and (F) Distributions from Alaska Native Corporations and Settlement Trusts. (b) Amounts received as a lump sum are counted as income only in the month received (see also Oklahoma Administrative Code (OAC) 317:35-10-26), with the exception of certain lottery or gambling winnings as specified in OAC 317:35-6-55. If a lump sum amount is received from an income source that is not counted in MAGI according to section 36B(d)(2)(B) of the Internal Revenue Code or the exceptions listed in this section, the amount is not counted.

Amounts subtracted from gross income to calculate MAGI for a household are defined in Section 36B of the Internal Revenue Code. No other deductions are applicable, except the subtraction of 5 percent from the percentage of FPL as provided in OAC 317:35-6-39.

(a) Use of current monthly income. Current monthly income is used in determinations of financial eligibility at application, when a member reports a change in circumstances, and at renewal. See 317:35-6-39 for potential exceptions. (b) Calculation of monthly income. For computation of monthly income, see OAC 317:35-10-26(e). (c) Anticipated income. Income which can reasonably be anticipated to be received is considered to be available for the month its receipt is anticipated. (d) Expected changes in income. Reasonably predictable future increases or decreases in income, such as for contract or seasonal employees, are prorated over the year the income is expected to support the household. The predicted annual amount of the income is divided by 12 to reach the monthly amount. (e) Lump sum income. Whether a particular lump sum is counted in household income depends first on whether the source of the lump sum is a countable source of income according to OAC 317:35-6-50 and OAC 317:35-6-51. See also OAC 317:35-10-26 for detailed rules regarding lump sum income.

(a) Expenses or losses that qualify as deductions for MAGI according to OAC 317:35-6-52 are totaled to reach an annual amount. The annual amount is then divided by 12 and subtracted from gross monthly income to calculate the household's current monthly MAGI. (b) Whether a deduction is allowed when it has already been paid or when it has only been incurred is determined in accordance with Section 36B of the Internal Revenue Code.

(a) Definitions. The following words and terms, when used in this section, shall have the following meaning, unless the context clearly indicates otherwise: (1) "Qualified lottery winnings" means winnings from a sweepstakes, lottery, or pool described in paragraph three (3) of Section 4402 of the Internal Revenue Code of 1986 or a lottery operated by a multistate or multijurisdictional lottery association paid out in a single payout and not in installments over a period of time. (2) "Qualified gambling winnings" means monetary winnings from gambling, as defined by Section (§) 1955(b)(4) of Title 18 of the United States Code (U.S.C.). (3) "Undue hardship" means circumstances resulting from a loss or denial of SoonerCare eligibility that would deprive an individual of medical care, such that the individual's health or life would be endangered, or that would deprive the individual or his or her financially dependent family members of food, clothing, shelter, or other necessities of life. (b) Income determinations. In accordance with 42 U.S.C. § 1396a(e)(14)(K), qualified lottery and gambling winnings shall be considered as income in determining the financial eligibility of individuals whose eligibility is determined based on the application of Modified Adjusted Gross Income (MAGI), as follows: (1) Winnings less than $80,000 are counted in the month received; (2) Winnings greater than or equal to $80,000, but less than $90,000, are counted as income over two (2) months, with an equal amount counted in each month; (3) Winnings greater than or equal to $90,000, but less than $100,000, are counted as income over three (3) months, with an equal amount counted in each month; (4) Winnings greater than or equal to $100,000 are counted as income over three (3) months, with one (1) additional month for every increment of $10,000 in winnings received over $100,000, with an equal amount counted in each month; and (5) The maximum period of time over which winnings may be counted is one hundred and twenty (120) months, which would apply to winnings greater than or equal to $1,260,000. (c) Treatment of household members. Qualified lottery and gambling winnings shall be counted as household income for all household members in the month of receipt; however, the requirement to count qualified lottery and gambling winnings in household income over multiple months applies only to the individual receiving the winnings. (d) Undue hardship. An individual who loses or is denied eligibility due to qualified lottery or gambling winnings may timely file a member appeal, in accordance with Oklahoma Administrative Code 317:2-1-2. If, as part of that appeal, the individual proves by a preponderance of the evidence that loss or denial of eligibility would result in undue hardship, eligibility shall be restored or approved, provided all other conditions of eligibility have been met. (e) Notice. SoonerCare members or applicants who are determined financially ineligible due to the counting of lottery or gambling winnings will receive a notice of the date on which the lottery or gambling winnings will no longer be counted for eligibility purposes. The notice will also inform the member or applicant of the undue hardship exemption and of their opportunity to enroll in a Qualified Health Plan on the Federally Facilitated Exchange.

(a) General rules of certification. (1) An individual determined eligible for SoonerCare may be certified for a prospective period of coverage on or after the date of certification. (2) In accordance with 42 Code of Federal Regulations (C.F.R.) § 435.915 and Oklahoma Administrative Code (OAC) 317:35-6-60.2, an individual may also be determined eligible and certified for a retroactive period of coverage during the three (3) month period directly prior to the date of application. This only applies if the individual received covered medical services at any time during that period and would have been eligible for SoonerCare at the time he or she received the services, regardless of whether the individual is alive when application for Medicaid is made. An individual may be eligible for the retroactive period even though ineligible for the prospective period. (3) The individual who is categorically needy and related to pregnancy-related services retains eligibility for the period covering prenatal, delivery, and postpartum periods without regard to eligibility for other household members in the case. Eligibility during the postpartum period does not apply to women receiving pregnancy-related coverage under Title XXI. (b) Certification of non-cash assistance individuals related to the children and parent and caretaker relative groups. The certification period for the individual related to the children or parent and caretaker relative groups is twelve (12) months. The certification period can be less than twelve (12) months if the individual: (1) Is certified as eligible in a money payment case during the twelve-month (12-month) period; (2) Is certified for long-term care during the twelve-month (12-month) period; (3) Becomes ineligible for SoonerCare after the initial month, except for children who are eligible for twelve months continuous coverage; or (4) Becomes financially ineligible. (A) If an income change after certification causes the case to exceed the income standard, the case is closed. (B) Individuals, however, who are determined pregnant and financially eligible continue to be eligible for pregnancy-related services through the prenatal, delivery and postpartum period, regardless of income changes. (c) Certification of individuals related to pregnancy-related services. The certification period for the individual related to pregnancy-related services will cover the prenatal, delivery and postpartum periods. The postpartum period is defined as the twelve (12) months following the month the pregnancy ends. Financial eligibility is based on the income received in the first month of the certification period. No consideration is given to changes in income after certification. (d) Certification of newborn child deemed eligible. (1) Every newborn child is deemed eligible on the date of birth for SoonerCare when the child is born to a woman who is eligible for and enrolled in pregnancy-related services as categorically needy. The newborn child is deemed eligible through the last day of the month the newborn child attains the age of one (1) year. The newborn child's eligibility is not dependent on the mother's continued eligibility. The mother's coverage may expire at the end of the postpartum period; however, the newborn child is deemed eligible until age one (1). The newborn child's eligibility is based on the original eligibility determination of the mother for pregnancy-related services, and consideration is not given to any income or resource changes that occur during the deemed eligibility period. (2) The newborn child is deemed eligible for SoonerCare as long as he/she continues to live in Oklahoma. In accordance with 42 C.F.R. § 435.117, no other conditions of eligibility are applicable, including social security number enumeration, child support referral, and citizenship and identity verification. However, it is recommended that social security number enumeration be completed as soon as possible after the newborn child's birth. It is also recommended that a child support referral be completed, if needed, as soon as possible and sent to the Oklahoma Child Support Services (OCSS) division at DHS. The referral enables child support services to be initiated. (3) When a categorically needy newborn child is deemed eligible for SoonerCare, he/she remains eligible through the end of the month that the newborn child reaches age one (1). If the child's eligibility is moved from the case where initial eligibility was established, it is required that the newborn receive the full deeming period. The certification period is shortened only in the event the child: (A) Loses Oklahoma residence; or (B) Expires. (4) A newborn child cannot be deemed eligible when the mother's only coverage was presumptive eligibility, and continued eligibility was not established.

(a) Reporting changes. Members are required to report changes in their circumstances within ten (10) days of the date the member is aware of the change. (b) Agency action on changes in circumstances. When the agency responsible for determining eligibility for the member becomes aware of a change in the member's circumstances, the agency will promptly redetermine eligibility for all household members whose eligibility is affected by the change. (c) Changes reported by third parties. When the agency receives information regarding a change in the member's circumstances from a third party, such as the Oklahoma Employment Security Commission (OESC) or the Social Security Administration (SSA), the agency will determine whether the information received is reasonably compatible with the most recent information provided by the member. (1) If the information received is reasonably compatible with the information provided by the member, the agency will use the information provided by the member for determinations and redeterminations of eligibility. (2) If the information received is not reasonably compatible with the information provided by the member, the agency will determine whether the information received will have an effect on the eligibility of any member of the household. (A) If the information received has no effect on the eligibility of any member of the household, including the benefit package the member is enrolled in, the agency will take no action. (B) If the information received has an effect on the eligibility of a member of the household, the agency will request more information from the member, including, but not limited to, an explanation of the discrepancy or verification documenting the correct information regarding the factor of eligibility affected by the information received from a third party. (C) The agency will give the member proper notice of at least 10 days to respond to the agency's request for information. (D) If the member does not cooperate in resolving the discrepancy within the timeframe established by the notice, benefits will be terminated. (d) Changes in a continuous eligibility period for children. During a continuous eligibility period for children, a member must report: (1) A change of address for the child; or (2) If a certified child leaves the home, is institutionalized, or dies.

(a) Retroactive eligibility, as outlined in this section, shall be available to pregnant women and/or members under the age of nineteen (19). For retroactive eligibility rules related to other SoonerCare population groups, refer to Oklahoma Administrative Code (OAC) 317:35-7-60(b). (b) In addition to the period of eligibility specified in Oklahoma Administrative Code (OAC) 317:35-6-60, an applicant, or individuals within the applicant's household, shall be eligible for SoonerCare benefits up to three (3) months prior to the date of application if all of the following requirements are met: (1) The individual for whom retroactive coverage is being requested would have been eligible for SoonerCare coverage if an application for SoonerCare had been made during the retroactive month. (A) The individual does not have to be eligible for the month of application to be found eligible for one (1) of the three (3) retroactive months. (B) The eligibility factors (e.g. income, residency, household composition, etc.) are evaluated separately for each retroactive month for which retroactive eligibility is being requested. (2) The applicant completes the retroactive eligibility application form and provides, within six (6) months of the date the services were provided, documentation for verification purposes as requested by SoonerCare. (3) The individual applying for retroactive coverage states that the individual for whom retroactive coverage is being requested received reimbursable SoonerCare services which were provided by a SoonerCare-contracted provider during the retroactive month. (4) An applicant cannot be approved for retroactive coverage for a month in which his or her application was previously denied. (c) Per 42 Code of Federal Regulations (CFR) § 435.915(b), if an applicant is determined to be eligible for retroactive coverage at any time during the requested retroactive month, then coverage will begin on the first (1 st ) day of the month and be effective for the entire month. (d) If the applicant is applying for SoonerCare benefits due to pregnancy, then the applicant must have been pregnant during the requested retroactive month. (e) Regardless of retroactive eligibility being granted, the requirement for the claim to be filed timely, per OAC 317:30-3-11, is still in effect. (f) Retroactive coverage for SoonerCare health services received during a retroactive month will be secondary to any third-party which has primary responsibility for payment. If the individual eligible for retroactive coverage has already paid for the health services, the provider may refund the payment and bill SoonerCare in accordance with the timely filing requirements in OAC 317:30-3-11. (g) Retroactive coverage for SoonerCare reimbursable health services that require prior authorization shall not be denied solely because of a failure to secure prior authorization. Medical necessity, however, must be established before reimbursement can be made. (h) Denials of requests for retroactive eligibility may be appealed in accordance with OAC 317:2-1-2(d)(1)(F).

(a) A periodic redetermination of eligibility for SoonerCare is required for all members. The redetermination is made prior to the end of the initial certification period and each twelve (12) months thereafter. A deemed newborn is eligible through the last day of the month the newborn child attains the age of one year, without regard to eligibility of other household members in the case. (b) Effective January 1, 2014, when the agency has sufficient information available electronically to redetermine eligibility, eligibility will be redetermined on that basis and a notice will be sent to the household explaining the action taken by the agency. The member is responsible for notifying the agency if any information used to redetermine eligibility is incorrect. If the agency does not have sufficient information to redetermine eligibility, the agency will send notice to that effect, and the member is responsible for providing the necessary information to redetermine eligibility. (c) A member's case is closed if he/she does not return the form(s) and any verification necessary for redetermination timely. If the member submits the form(s) and verification necessary for redetermination within ninety (90) days after closure of the case, benefits are reopened effective the date of the closure, provided the member is eligible and benefits were closed because the redetermination process was not completed. (d) Effective January 1, 2024, a child who meets the criteria for continuous eligibility shall remain eligible for SoonerCare, until the earlier of: (1) Twelve (12) months from the effective date of the child’s most recent certification period; or (2) The child's nineteenth (19 th ) birthday.

If the denial of SoonerCare is for the entire household, the appropriate notice is computer generated to the applicant. If an individual(s) is being denied but other family members are eligible, the denied individual(s) is provided with a notice.

SoonerCare cases are closed at any time during the certification period that the case becomes ineligible. A computer-generated notice is sent to the head of the household.

(a) Conditions for TMA. (1) Transitional Medical Assistance. Health benefits are continued when the benefit group loses eligibility due to new or increased earnings of the parent(s)/caretaker relative or the receipt of spousal support. The health benefit coverage is of the same amount, duration, and scope as if the benefit group continued receiving SoonerCare. Eligibility for TMA begins with the effective date of case closure or the effective date of closure had the income been reported timely. An individual is included for TMA only if that individual was eligible for SoonerCare and included in the benefit group at the time of the closure. To be eligible for TMA the benefit group must meet all of the requirements listed in (A) - (C) of this paragraph. (A) At least one member of the benefit group was included in at least three of the six months immediately preceding the month of ineligibility. (B) The health benefit cannot have been received fraudulently in any of the six months immediately preceding the month of ineligibility. (C) The benefit group must have included a dependent child who met the age and relationship requirements for SoonerCare and whose needs were included in the benefit group at the time of closure, unless the only eligible child is a Supplemental Security Income (SSI) recipient. (2) Closure due to spousal support. Health benefits are continued if the case closure is due to the receipt of new or increased payments for spousal support in the form of alimony. The needs of the parent(s)or caretaker relative must be included in the benefit group at the time of closure. The health benefits are continued for four months. (3) Closure due to new or increased earnings of parent(s) or caretaker relative. Health benefits are continued if the closure is due to the new or increased earnings of the parent(s) or caretaker relative. The needs of the parent(s)or caretaker relative must be included in the benefit group at the time of closure. The parent(s) or caretaker relative is required to cooperate with OKDHS Oklahoma Child Support Services during the period of time the family is receiving TMA. (4) Eligibility period. Health benefits may be continued for a period up to 12 months if the reason for closure is new or increased earnings of the parent(s) or caretaker relative. This period is divided into two six-month periods with eligibility requirements and procedures for each period. (A) Initial six-month period. (i) The benefit group is eligible for an initial six-month period of TMA without regard to income or resources if: (I) an eligible child remains in the home; (II) the parent(s) or caretaker relative remains the same; and (III) the benefit group remains in the state. (ii) An individual benefit group family member remains eligible for the initial six-month period of TMA unless the individual: (I) moves out of the state, (II) dies, (III) becomes an inmate of a public institution, (IV) leaves the household, (V) does not cooperate, without good cause, with the OKDHS Oklahoma Child Support Services or third party liability requirements. (B) Additional Six-month period. (i) Health benefits are continued for the additional six-month period if: (I) an eligible child remains in the home; (II) the parent(s) or caretaker relative remains the same; (III) the benefit group remains in the state; (IV) the benefit group was eligible for and received TMA for each month of the initial six-month period; (V) the benefit group has complied with reporting requirements in subsection (g) of this Section; (VI) the benefit group has average monthly earned income (less child care costs that are necessary for the employment of the parent or caretaker relative) that does not exceed the 185% of the Federal Poverty Level (see SoonerCare Income Guidelines); and (VII) the parent(s) or caretaker relative had earnings in each month of the required three-month reporting period described in (g)(2) of this Section, unless the lack of earnings was due to an involuntary loss of employment, illness, or other good cause. (ii) An individual benefit group family member remains eligible for the additional six-month period unless the individual meets any of the items listed in (4)(A)(ii) of this paragraph. (b) Income and resource eligibility. (1) The unearned income and resources of the benefit group are disregarded in determining eligibility for TMA. There is no earned income test for the initial six-month period. (2) Health benefits are continued for the additional six-month period if the benefit group's countable earnings less child care costs that are necessary for the employment of the parent(s) or caretaker relative are below 185% of the Federal Poverty Level (see the standards on the OHCA website or the OKDHS Form 08AX001E, Schedule I.A) and the benefit group meets the requirements listed in (a)(4)(B). (A) The earnings of all benefit group members are used in determining the earned income test. The only exception is that earnings of full time students included in the benefit group are disregarded. (B) Income is determined by averaging the benefit group's gross monthly earnings (except full time student earnings) for the required three-month reporting period. (C) A deduction from the benefit group's earned income is allowed for the cost of approved child care necessary for the employment of the parent(S) or caretaker relative. The child care deduction is averaged for the same three-month reporting period. There is no maximum amount for this deduction. (D) All individuals whose earnings are considered are included in the benefit group. The family size remains the same during both reporting periods. (c) Eligible child. When the SoonerCare benefit is closed and TMA begins, the benefit group must include an eligible child whose needs were included in the SoonerCare benefit at the time of closure, unless the only eligible child is a SSI recipient. After the TMA begins, the benefit group must continue to include an eligible child. Age is the only requirement an eligible child must meet. (d) Additional members. After the TMA begins, family members who move into the home cannot be added to the TMA coverage. This includes siblings and a natural or adoptive parent(s) or caretaker relative. If the additional member is in need of health benefits, an application for services under the SoonerCare program is completed. If a benefit group member included in TMA leaves the home and then returns, that member may be added back to TMA coverage if all conditions of eligibility are met. (e) Third party liability. The benefit group's eligibility for TMA is not affected by a third party liability. However, the benefit group is responsible for reporting all insurance coverage and any changes in the coverage. The worker must explain the necessity for applying benefits from private insurance to the cost of medical care. (f) Notification. (1) Notices. Notices are sent to the benefit group, both at the onset of and throughout the TMA period. These notices, which are sent at specific times, inform the benefit group of its rights and responsibilities. When SoonerCare is closed and the benefit group is eligible for TMA, the computer generated closure notice includes notification of the continuation of health benefits. Another computer generated notice is sent at the same time to advise the benefit group of the reporting requirements and under what circumstances the health benefits may be discontinued. Each notice listed in (A)-(C) of this paragraph includes specific information about what the benefit group must report. The notices serve as the required advance notification in the event benefits are discontinued as a result of the information furnished in response to these notices. (A) Notice #1. Notice #1 is issued in the third month of the initial TMA period. This notice advises the benefit group of the additional six-month period of TMA, the eligibility conditions, reporting requirements, and appeal rights. (B) Notice #2. Notice #2 is issued in the sixth month of the TMA period, but only if the benefit group is eligible for the additional six-month period. This notice advises the benefit group of the eligibility conditions, reporting requirements, and appeal rights. (C) Notice #3. Notice #3 is issued in the ninth month of the TMA period, or the third month of the additional six-month period. This notice advises the benefit group of the eligibility conditions, the reporting requirements, appeal rights, and the expiration of TMA coverage. (2) Notices not received. In some instances the benefit group does not receive all of the notices listed in (1) of this subsection. The notices and report forms are not issued retroactively. (g) Reporting. The benefit group is required to periodically report specific information. The information may be reported by telephone or by letter. (1) The benefit group must report: (A) gross earned income of the entire benefit group for the appropriate three-month period; (B) child care expenses, for the appropriate three-month period, necessary for the continued employment of the parent(s) or caretaker relative; (C) changes in members of the benefit group; (D) residency; and (E) third party liability. (2) The reporting requirement time frames are explained in this subparagraph. (A) The information requested in the third month must be received by the 21st day of the fourth month and is used to determine the benefit group's eligibility for the additional six-month period. While this report is due in the fourth month, negative action cannot be taken during the initial period for failure to report. If the benefit group fails to submit the requested information, benefits are automatically suspended effective the seventh month. If action to reinstate is not taken by deadline of the suspension month, the computer automatically closes the case effective the next month. (B) The information requested in the sixth month must be furnished by the 21st day of the seventh month. The decision to continue benefits into the eighth month is determined by the information reported. (C) The information requested in the ninth month must be furnished by the 21st day of the tenth month. The decision to continue health benefits into the 11th month is determined by the information reported. When the information is not reported timely, the TMA is automatically suspended by the computer for the appropriate effective date. If the benefit group subsequently reports the necessary information, the worker determines eligibility. If all eligibility factors are met during and after the suspension period, the health benefits are reinstated. The effective date of the reinstatement is the same as the effective date of the suspension so the benefit group has continuous medical coverage. (h) Termination of TMA. The TMA coverage is discontinued any time the benefit group fails to meet the eligibility requirements as shown in this Section. If it becomes necessary to discontinue the TMA coverage for the benefit group or any member of the benefit group, the individual(s) must be advised that he or she may be eligible for health benefits under the SoonerCare program and how to obtain these benefits. (i) Receipt of health benefits after TMA ends. To ensure continued medical coverage a computer generated recertification form is mailed to the benefit group during the third month of TMA for benefits closed due to the receipt of child or spousal support or the 11th month of TMA for benefits closed due to increased earnings. The benefit group must return the form prior to the termination of the TMA benefits. When determined eligible, health benefits continue as SoonerCare, not TMA. If the benefit group fails to return the recertification form, TMA benefits are terminated.

Case records on Health Benefits applications, active cases or closed cases are transferred in accordance with OAC 340:65.