Okla. Admin. Code § 340:10-3-75

Current through Vol. 42, No. 7, December 16, 2024

Section 340:10-3-75 - Continued medical benefits (CMB)

(a)Conditions for CMB. The Temporary Assistance for Needy Families (TANF) assistance unit is eligible to receive CMB for the time period described in (b) or (c) of this Section following TANF benefit closure due to child or spousal support receipt or new or increased earnings of the TANF payee provided the payee is included in the benefit, per Section 408 of the Social Security Act, Section 608 of Title 42 of the United States Code. The medical coverage for CMB recipients is the same as for TANF recipients. CMB eligibility begins effective the TANF benefit closure date or the effective date of closure had the income been reported timely. Only persons included in the assistance unit when the TANF benefit is closed are eligible for CMB. To be eligible for CMB the assistance unit must meet all of the requirements listed in (1) - (5) of this subsection.

(1) At least one member received TANF in at least three of the six months immediately preceding the month the TANF benefit closed.

(2) The payee must be included in the TANF benefit in the month of closure and remain as payee during CMB receipt.

(3) The assistance unit did not fraudulently receive TANF benefits in the six months preceding TANF closure. Refer to Oklahoma Administrative Code (OAC) 340:65-9-4 for fraudulent receipt rules.

(4) The assistance unit must include an eligible child.

(A) An eligible child is a child who is included in the TANF cash assistance benefit in the closure month and continues to meet age requirements, per OAC 340:10-5-1 and relationship requirements, per OAC 340:10-9-1 while receiving CMB.

(B) A child who is not included in the TANF cash assistance benefit because of Supplemental Security Income receipt is also considered an eligible child when he or she is the only child in the home meeting age and relationship requirements.

(C) The eligible child must have met deprivation requirements, per OAC 340:10-10-1 prior to TANF benefit closure but is not subject to deprivation requirements during the CMB eligibility period.

(5) The payee must comply with Soonercare (Medicaid) citizenship and identity verification rules, per OAC 317:35-5-25.

(b)Closure due to child support or spousal support. Medical benefits are continued for up to four months when the TANF closure is due to the receipt of new or increased child support or spousal support in the form of alimony.

(c)Closure due to new or increased earnings of payee. Medical benefits may be continued for up to 12 months when the closure is due to the payee's new or increased earnings. When the payee is the natural or adoptive parent and deprivation is due to the other parent's absence , he or she is required to cooperate with Oklahoma Child Support Services (CSS) while receiving CMB.

(1)Eligibility. The CMB eligibility period is divided into two, six-month periods with eligibility requirements and procedures for each period.

(A)Initial six-month period. The assistance unit is eligible for CMB when:

(i) an eligible child remains in the home per (a)(4) of this Section;

(ii) the payee remains the same; and

(iii) the assistance unit remains in Oklahoma.

(B)Additional six-month period. Medical benefits are continued for the additional six month period when:

(i) an eligible child remains in the home per (a)(4) of this Section;

(ii) the payee remains the same;

(iii) the assistance unit remains in Oklahoma;

(iv) the assistance unit was eligible for and received CMB for each month of the initial six month period;

(v) the assistance unit complied with reporting requirements in (4) of this subsection;

(vi) the assistance unit's average monthly earned income does not exceed the income standard, per the Oklahoma Department of Human Services (DHS) Appendix C-1, Maximum Income, Resource, and Payment Standards, Schedule I. The income standard is based on 185 percent of the federal poverty level; and

(vii) the payee had earnings in each month of the three-month reporting period, unless the lack of earnings was due to an involuntary loss of employment, illness, or other good cause.

(C)Income eligibility for additional six-month period. The worker determines income eligibility for the additional six-month period per rules in (i) through (iii) of this subparagraph.

(i) The worker disregards the assistance unit's:

(I) unearned income;

(II) a child's earned income when the child is a full time student; and

(III) resources.

(ii) The gross earnings of all assistance unit members minus the payee's child care expenses incurred for employment purposes must not exceed the income standard per household size on DHS Appendix C-1, Schedule I. To determine income eligibility over the three-month reporting period, the worker averages the:

(I) entire assistance unit's gross monthly earnings;

(II) family size when changes occurred per (D) of this subsection; and

(III) child care expenses. There is no maximum amount for this deduction.

(iii) The earnings of an additional family member are considered only when the member is a natural or adoptive parent. When the additional family member's earnings are considered, he or she is included in the household size for the income test.

(D)Additional members. After the CMB begins, the worker:

(i) does not add family members who move into the home to the CMB coverage. This includes siblings and a natural or adoptive parent(s). When the additional member needs medical services, the worker refers the payee to the Oklahoma Health Care Authority (OHCA) online enrollment system at www.mysoonercare.org to complete an application for the additional member. The payee may also complete an application at the local health department, Indian clinic, participating health care provider, or county office; and

(ii) adds a child younger than one year of age to the CMB coverage when the child is deprived of parental support, per OAC 340:10-10-1 and the child's mother is included in the CMB coverage.

(E)Assistance unit member leaves home and returns. When an assistance unit member included in the CMB leaves the home and then returns, he or she may be added back to the CMB coverage when all conditions of eligibility are met, provided the member is not the payee.

(F)Third party liability. The assistance unit remains eligible for CMB when it obtains health insurance coverage. However, the assistance unit is responsible for reporting all insurance coverage and any changes in the coverage as third party liability must be considered. The worker is responsible for explaining third-party liability and the necessity for filing medical claims with the private insurance before filing with OHCA.

(G)CMB closure. The worker closes the CMB any time the assistance unit fails to meet the eligibility requirements included in this Section. When the worker closes the CMB for the assistance unit or any member of the assistance unit, the worker informs the payee that the assistance unit or the member may complete an application for medical benefits under the regular SoonerCare (Medicaid) Program by accessing OHCA's online enrollment system at www.mysoonercare.org or completing an application at the local health department, Indian clinic, participating health care provider, or county office.

(2)Notification. DHS sends notices to the assistance unit when CMB is approved and throughout the CMB period. The notices are sent at specific times and inform the assistance unit of its rights and responsibilities. When a TANF benefit closes and the assistance unit is eligible for CMB, the computer-generated closure notice includes notification of the continuation of medical benefits. DHS sends another computer-generated notice at the same time to inform the assistance unit of the reporting requirements and under what circumstances the medical benefits may be discontinued. Each notice listed in (A) through (C) of this paragraph includes specific information about the assistance unit's reporting responsibilities and serves as the required advance notification in the event benefits are closed because of the information furnished in response to these notices or because the payee does not respond to the notices.

(A)Notice # 1. PSNCM1 issues in the third month of the initial continued medical eligibility period. This notice informs the assistance unit of the additional six-month period of CMB, the eligibility conditions, reporting requirements, and appeal rights.

(B)Notice # 2. PSNCM2 issues in the sixth month of the continued medical eligibility period only when the assistance unit is eligible for the additional six-month period. This notice informs the assistance unit of the eligibility conditions, reporting requirements, and appeal rights.

(C)Notice # 3. PSNCM3 issues in the ninth month of the continued medical eligibility period, which is the third month of the additional six-month period. This notice informs the assistance unit of the eligibility conditions, the reporting requirements, appeal rights, and the expiration of CMB coverage.

(3)Notices not received. When the assistance unit does not receive all of the notices listed in (2)(A) through (C) of this subsection, the notices and report forms are not issued retroactively. When the payee notifies the worker he or she did not receive a notice or report form, the worker obtains required information necessary to establish the assistance unit's continued eligibility from the payee and informs him or her to provide earned income proof for the appropriate reporting period.

(4)Reporting. The assistance unit is required to periodically report specific information necessary to determine the assistance unit's continued eligibility for CMB. To assist the unit, computer-generated Form 08TA018E, Continued Medical Benefit Reply Form, is sent to the assistance unit with the notices generated during the CMB period. Though preferred, it is not mandatory that Form 08TA018E be returned. The payee may report the information by phone, in an office interview, or by letter. The payee must provide proof of all gross earnings for the three-month reporting period.

(A) The assistance unit must report:

(i) the gross earned income of the entire assistance unit for the appropriate three-month period;

(ii) employment-related child care expenses paid by the payee for the appropriate three-month period;

(iii) any changes in the members of the assistance unit;

(iv) any residency changes; and

(v) insurance coverage information.

(B) The reporting requirement time frames are explained in this subparagraph.

(i) The payee must report required information in the third month and return earned income proof by the 12th day of the fourth month. The worker evaluates the information provided to determine the assistance unit's eligibility for the additional six-month period. Even though the payee is required to report required information in the fourth month, no negative action occurs during the initial six-month period for failure to report. When the:

(I) assistance unit returns required information and no longer meets eligibility conditions per (1) of this subsection, the worker closes CMB effective the first day of the seventh month; or

(II) payee fails to report required information and submit earned income proof, CMB automatically suspend effective the first day of the seventh month. When the worker does not reinstate CMB by the advance notice deadline of the suspension month, per DHS Appendix B-2, Deadlines for Case Actions, CMB automatically closes effective the next month.

(ii) The payee must report required information requested in the sixth month and return required earned income proof by the 12th day of the seventh month. When the:

(I) assistance unit returns required information and no longer meets eligibility conditions per (1) of this subsection, the worker closes CMB effective the first day of the eighth month; or

(II) payee fails to report required information and submit earned income proof, CMB automatically suspends effective the first day of the eighth month. When the worker does not reinstate CMB by advance notice deadline of the suspension month, per DHS Appendix B-2 CMB automatically closes effective the next month.

(iii) The payee must report required information requested in the ninth month and return required earned income proof by the 12th day of the tenth month. When the:

(I) assistance unit returns required information and no longer meets eligibility conditions per (1) of this subsection, the worker closes CMB effective the first day of the eleventh month; or

(II) payee fails to report required information and return required earned income proof by the 12th day of the tenth month, CMB automatically suspends effective the first day of the eleventh month. When the worker does not reinstate CMB by advance notice deadline of the suspension month, per DHS Appendix B-2, CMB automatically closes effective the next month.

(5)CMB reinstatement. When the assistance unit subsequently reports the necessary information following suspension, the worker determines eligibility. When all eligibility factors are met during and after the suspension period, the worker reinstates the medical benefits effective the date of the suspension so the assistance unit has continuous medical coverage until the CMB period ends.

(d)Receipt of medical benefits after CMB ends. A computer-generated expiration notice is mailed to the assistance unit the month before the CMB period ends to explain how to apply for continued medical benefits. When the assistance unit applies and is determined eligible, medical benefits continue as regular SoonerCare (Medicaid) benefits, not CMB.

Okla. Admin. Code § 340:10-3-75

Amended at 10 Ok Reg 829, eff 1-1-93 (preemptive); Amended at 11 Ok Reg 323, eff 10-15-93 (emergency); Amended at 11 Ok Reg 1639, eff 5-12-94; Amended at 14 Ok Reg 947, eff 2-1-97 (emergency); Amended at 14 Ok Reg 1310, eff 5-12-97; Amended at 15 Ok Reg 145, eff 11-1-97 (emergency); Amended at 15 Ok Reg 1602, eff 5-11-98; Amended at 17 Ok Reg 2271, eff 5-1-00 (preemptive); Amended at 18 Ok Reg 1217, eff 6-1-01; Amended at 25 Ok Reg 14, eff 8-3-07 (emergency); Amended at 25 Ok Reg 903, eff 6-1-08; Amended at 26 Ok Reg 1223, eff 6-1-09

Amended by Oklahoma Register, Volume 34, Issue 24, September 1, 2017, eff. 9/15/2017

Amended by Oklahoma Register, Volume 37, Issue 24, September 1, 2020, eff. 9/15/2020