Library: Policy
317:35-19-21. Determining financial eligibility for care in nursing facility
Revised 7-1-21
Rule text available at Oklahoma Health Care Authority website.
INSTRUCTIONS TO STAFF 317:35-19-21
Revised 9-14-20
1. The formula for determining the vendor payment, when a community spouse (CS) is not in the home, is:
(1) the individual's countable income;
(2) minus the institutional or own home standard; and
(3) minus the verified countable medical expenses. Only subtract the actual monthly payments being made for medical insurance premiums, including Medicare premiums).
2. The own home standard is the categorically needy standard found on Oklahoma Department of Human Services (OKDHS) Appendix C-1, Maximum Income, Resource, and Payment Standards, Schedule VI.
3. The worker divides the couple's total resource amount by two to determine each spouse's share of the resources.
(1) In order for the institutionalized spouse (IS) to be financially eligible for SoonerCare, the resulting half of the resources attributed to him or her cannot exceed the maximum resource standard per OKDHS Appendix C-1, Schedule XI.
(2) When the CS's half of the resources is less than the minimum resource standard, per OKDHS Appendix C-1, Schedule XI, the worker reduces the IS's portion of the resources to the amount needed, to bring the CS's share of the resources up to the minimum standard.
(3) Example: Mr. H. is the IS. Mr. H.'s and his spouse's combined resources total $40,000. $20,000 of the resources are attributed to his spouse. Since this is less than the $25,284 current minimum standard, $5,284 of Mr. H's portion of the resources is deemed to his spouse.
4. (a) The worker completes Form 08MA012E, Title XIX Work Sheet, to determine the vendor payment for the IS when there is a CS in the home or when there is a CS and other dependents in the home.
(b) The formula for determining the vendor payment, when a CS remains in the home is, to:
(1) first determine the IS's monthly countable income, per Instructions to Staff # 1 of this Section; and
(2) then determine how much of the IS's income can be deemed to the CS by subtracting the CS's gross income from the maximum monthly income standard, per OKDHS Form Appendix C-1, Schedule XI.
(A) The resulting amount is the maximum amount that can be deemed from the IS to the CS.
(B) Any amount remaining is the vendor payment, when there are no minor dependent children, parents, or siblings residing with the CS.
(c) When, in addition to the CS, there are minor dependent children or dependent parents or siblings, of either spouse, residing in the home with the CS, a living allowance for the other dependent(s) must be subtracted from the IS's remaining income before determining the vendor payment.
(1) The worker divides the maximum monthly income standard, per DHS Form Appendix C-1, Schedule XI by three.
(2) The worker then subtracts the gross income of all dependents residing with the CS from the resulting amount in (b)(2)(A) of this Instruction.
(3) The remaining amount is deemed to the dependents residing with the CS.
(4) The worker adds together the deemed amount for the CS, per (b)(2)(A) of this Instruction, and the deemed amount for the other dependents, per (c)(3) of this Instruction, and subtracts the total from the IS's income, per (a)(1) of this instruction.
(5) Any amount remaining, after subtracting the deemed income, is the vendor payment.
