ENROLLMENT PROCEDURES MANUAL

Transcription

1 OKLAHOMA HEALTH CARE AUTHORITY HEALTH CARE AUTHORITY ONLINE ENROLLMENT ENROLLMENT PROCEDURES MANUAL ELIGIBILITY FREQUENTLY ASKED QUESTIONS

2 ONLINE ENROLLMENT PROCEDURES MANUAL Eligibility Frequently Asked Questions (FAQs) Step 1: People and Contacts How do I know if I am an eligible alien or not? An eligible alien includes legal permanent residents, refugees, persons who have been granted asylum, persons granted withholding of deportation or removal, Cuban/Haitian entrants, persons paroled into the U.S. for al least one year by immigration authorities, persons granted conditional entry pursuant to section 203(a)(7) of the Immigration and Naturalization Act, and certain victims of domestic violence or victims of human trafficking. (Also see below): Non-qualified aliens (those individuals who were admitted to the United States and who do not meet any of the definitions of eligible aliens) are ineligible for SoonerCare for five years from the date of entry except that they are eligible for emergency services only when the individual has a medical condition (including emergency labor and delivery) The only exception is when a pregnant woman qualifies under the pregnancy related benefits covered under the Title XXI program because the newborn child will meet the citizenship requirement at birth. Some Afghan Special Immigrants as defined in Public Law , who have special immigration status after December 26, 2007 may however be eligible for SoonerCare services for a limited period of time. The same applies to Iraqi special immigrants, as defined in Public Law , who have special immigration status after January 28, Undocumented aliens who do not meet any of the definitions above are eligible for emergency services only when the individual has a medical condition (including emergency labor and delivery) with acute symptoms which may result in placing his/her health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of body organ or part without immediate medical attention. The only exception is when a pregnant woman qualifies under the pregnancy related benefits covered under the Title XXI program because the newborn child will meet the citizenship requirement at birth. Ineligible aliens who do not fall into the categories above, yet have been lawfully admitted for temporary or specified periods of time include, but are not limited to: foreign students, visitors, foreign government representatives, crewmen, members of foreign media and temporary workers including agricultural contract workers. This group is ineligible for SoonerCare, including emergency services, because of the temporary nature of their admission status. The only exception is when a pregnant woman qualifies under the pregnancy related benefits covered under the Title XXI program because the newborn child will meet the citizenship requirement at birth.. 2

3 What if the non-citizen doesn t have their alien registration card with them? If the person doesn t have their alien registration number, the application cannot be submitted. You will have to save the application and enter the alien registration number when you find it. I don t remember the date of my last entry to the USA, how do I proceed? Check with your records and look for your USCIS Form I-94 (Arrival-Departure Record) which specifies the date you entered the USA. You can also check your passport for the USCIS arrival stamp which has the date of your entry to the USA. I don t have a SSN. Does it mean I am ineligible? No, you can still be eligible, but you need to call the Social Security Administration office and arrange to get a SSN if you are eligible for one. Federal regulations require that an individual must furnish, or show documentation of application for a Social Security number at the time of application. Documentation of application for a SSN number may include, but is not limited to, Form SSA-2853 or DHS Form Adm-101 (Social Security Number Enumeration Referral). Should I enter the SSN even if the person isn t sure of it? If the person has a general idea it s okay to enter the SSN. The SSN will be verified through data exchange. If this is a single adult who receives SSI, should I complete the online enrollment application? No. If the person receiving SSI is the only one on the application, he/she should apply through OKDHS instead. I don t know the insurance information for people in my household, what do I do? Consult with each individual in your household who has insurance to get the detailed insurance information about them and revisit the application process. The required information can be found on their individual insurance cards. Can I select more than one benefit (i.e. both SoonerCare and SoonerPlan benefits) in the application process? You can request for any or all programs but will only be approved for most beneficial of the ones for which you qualify. 3

4 If I want to add SoonerCare benefits for a new person in the household, is that a change or a new application? If you are adding a new person to the household, that is treated as a new application. I am an American Indian, how do I know if I am eligible for a CDIB card? American Indian/Alaska Native (AI/AN) means an individual of Native American descent who has or is eligible for a Certificate of Degree of Indian Blood (CDIB) card. Native Americans are usually identified by a CDIB (certificate of degree of Indian blood) card that is issued by the Bureau of Indian Affairs (BIA). You may want to contact the BIA about CDIB. I am not legally present in the U.S. but have lived long enough and fall within the vulnerable group for Medicaid. Can I qualify and do I have to apply? To qualify for SoonerCare, you must first apply for the program. A person must: Reside in Oklahoma; Be a U.S. citizen or qualified alien (most immigrants who arrived after August 22, 1996 are barred from the program for five years); Meet financial income and resources standards Pregnant women who are not in the U.S. legally can still qualify for SoonerCare during pregnancy, delivery and some months of post-partum For how long can my child continue to be on the SoonerCare program? A child born on SoonerCare is eligible until age 1, and may qualify after that depending on income. 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 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 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. 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. The newborn child is deemed eligible for SoonerCare as long as he/she continues to live in Oklahoma. I am in the U.S. illegally. Do I risk being handed over to the immigration authorities if I apply? No, there is no risk in applying. The OHCA is not an immigration enforcing agency and only asks for immigration status for the purpose of eligibility. 4

5 I live temporary in OK, can I apply/qualify? While health benefits coverage is available only to Oklahoma residents, there are limited benefits available to non-residents if they are: Pregnant and seeking emergency delivery services Seeking mental health and substance abuse assistance through the Oklahoma Department of Mental health and Substance Abuse Services. Otherwise, you can apply so long as you can establish proof of residency in Oklahoma. Your qualification for benefits will however depend on your ability to satisfy the various other requirements of the program. I work and pay income taxes in Oklahoma but live across from the state in Texas, can I apply for SoonerCare? You have to apply in Texas. I am an alien not categorized under type of alien (e.g. H1-B visa status). Am I eligible to apply? No. You fall under Ineligible Aliens. The only exception is when a pregnant woman qualifies under the pregnancy related benefits covered under the Title XXI program because the newborn child will meet the citizenship requirement at birth. I am pregnant but don t know how many babies expected, what should I do? You can go ahead and put 1 as the number of babies expected until you know for sure how many babies you are expecting. What if the pregnant woman doesn t know her due date? Go ahead and enter a date in the future. The pregnancy verification should include the correct due date, and this can be updated when the woman provides it. What is the relevance of an authorized representative in the application? It allows you to designate someone outside the household to contact the OHCA on your behalf. I have change of address and contact information, how do I update my records? You can create an account with a unique identification and password at the application page. You can then go back to the page and sign in to your account at any time to make any changes to your account. You can also call the OHCA at and update your records. 5

6 Step 2: Household Income: What constitutes a household? The household consists of you, your spouse, any children related to either of you, and any other person(s) in the house. If you are pregnant and the father of the child lives with you, include him. If the pregnant woman is under age 18 and lives with her parent(s), the parent(s) is considered a household member(s). Other minor siblings may be included as household members). Should I enter information for household member who only lives there part- time (for example, on the weekends or during the summer)? It depends. For example, if the person who only lives there part time is the parent who works out of town, the parent must be included. If it is a child who only lives there part-time, the adult the child lives with should complete the application for that child. If the parents are divorced but live together with the children, do I include both parents in the household? Yes, if you re only requesting SoonerCare for the children. If one or both parents want SoonerCare for themselves, they will have to complete a separate request which doesn t include the ex-spouse as a household member. I receive child support on an irregular basis, will that affect my chances of qualifying? Monthly income received in fluctuating amounts, i.e. income which is received monthly but in irregular amounts is averaged using two month's income, if possible, to determine income eligibility. I don t have regular monthly income. How will my eligibility be determined? All qualifying income received by your household will be used in determining your eligibility. Example include incomes of migrant workers. What if the applicant has new employment and isn t sure how much she makes? Go ahead and enter what the applicant thinks the income is and ask them to provide the correct information when they get it. My household income is above the federal poverty level but don t earn enough to enable me purchase health insurance. What form of assistance can I be offered? Your situation will be carefully reviewed based on the information you provide and an assessment will be made to determine what benefit you may qualify for. 6

7 You may also be eligible for the Insure Oklahoma or the High-Risk Pool Coverage Programs. Call the OHCA at for enquiries. I receive assistance from the SNAP program. Will that change my household income composition and render me ineligible? No. Each application is reviewed and evaluated based on need as well as the eligibility guidelines. Income that is disregarded in determining eligibility includes: Food Stamp benefits; student loans; education grants and loans (regardless of use) if a bona fide debt or obligation to pay can be established. Others are Experimental Housing Allowance Program (EHAP) payment; government rental or housing subsidies by governmental agencies; earnings of a child who is a full-time student; advance payments of Earned Income Tax Credit (EITC) or refunds of EITC for filing a federal income tax return and the first $50 of the current monthly child support paid by an absent parent. If an adult or child from the family group is living in the home and is receiving SSI, his/her individual income is considered by the Social Security Administration in determining eligibility for SSI. Therefore, that income cannot be considered as available to the benefit group. What if I discover there s an error but I ve already submitted the application? You should log back into the system and enter the correct information. Step 3: Child Care Expenses I pay child care expenses but not to a licensed caregiver. How do I treat this? You can just put down the amount of money paid to the unlicensed caregiver and the frequency of payment. Step 4: Absent Parents I don t know the absent parent DOB and SSN, what should I do? You should put all information you know about the absent parent into the system. Cooperation with Child Support Enforcement is required if a client has a parent absent from the home and they are applying for themselves to be covered on SoonerCare. Cooperation with Child Support Enforcement is not however required if they are pregnant, or only covering children under 18 years old. 7

8 Step 5: Health Insurance How do I apply for the Family Planning Waiver (FPW) and what are the benefits of the FPW program? The application process is the same as in SoonerCare, but you only have to check SoonerPlan as your optional benefit. The FPW or SoonerPlan is Oklahoma s family planning program for uninsured women and men who are not enrolled in regular SoonerCare services. To qualify, you must satisfy the following criteria: Age 19 or older; Not already had a surgery which prevents pregnancy; U.S. citizen or qualified alien; Oklahoma resident; Not enrolled in regular SoonerCare; Without creditable health insurance coverage; Within the income standard (185 percent of Federal Poverty Level What do I do after applying for the program? You will be given an instant feed back by the system after you apply online to know if you do qualify. If you make a paper application, the OHCA staff will review your application and notify you of the status at a later date. What is the Breast and Cervical Cancer (BCC) Program? The BCC Program provides Medicaid to uninsured women under age 65 who are in need of treatment for breast and/or cervical cancer. Medical eligibility is determined through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) as needing treatment for breast and/or cervical cancer, including pre-cancerous conditions and early stage, recurrent or metastatic cancer. For more information about the BCC program, call the OHCA hotline at The BCC Program is not part of SoonerCare and can be applied for in a separate application. To receive BCC treatment services, one must meet all of the following conditions: (1) The woman must have been screened for BCC and found to be in need of treatment (2) The woman must: not have creditable insurance coverage that covers BCC not be eligible for any other categorically needy Medicaid eligibility group be under 65 years of age be a US citizen or qualified alien be a resident of Oklahoma declare her Social Security number 8

9 assign her rights to Third Party Liability if she has insurance that is not creditable, and declare her household income for the purpose of determining that she is not otherwise eligible for Medicaid. For the BCC treatment program, income is not a condition of eligibility and verification of income is not required. What is considered Creditable Health Insurance under the BCC Program? Examples of Creditable Health Insurance include the following: Coverage under a group health plan; Health insurance coverage, i.e., benefits consisting of medical care under any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance organization contract offered by a health insurance issuer Medicare Part A and/or B Medicaid Armed Forces insurance A state health risk pool How do I change benefit programs? You can always change benefit programs, provided you satisfy the eligibility requirements of the benefit program you seek to obtain. Just go online or to the DHS office and apply for your desired program. You can also call OHCA at If the payee dies or is no longer in the home, do we have to close the case for children? The system doesn t allow eligibility to remain open for the children if there s no adult in the household. The case can be closed and a new one opened for the children with their new household. There are provisions for setting up child-only cases when appropriate. What is SoonerCare? SoonerCare (Oklahoma Medicaid) is a health coverage program jointly funded by the federal and state governments. This program helps pay some or all medical bills for many people who can't afford them. The Oklahoma Health Care Authority (OHCA) is the state agency that administers the program. The Oklahoma Department of Human Services (OKDHS) determines financial eligibility for the program. In general, the following groups of individuals may qualify for SoonerCare services: Men and women 19 and older with family planning needs Adults with children under 19 9

10 Children under 19 and pregnant women Individuals 65 and older Individuals who are blind or who have disabilities Women under 65 in need of breast or cervical cancer treatment. Should I enter health insurance information if I don t know the policy number? The number is required if you have insurance. Can I get prescription assistance in the SoonerCare program? Depending on the category in which you fall, you can get prescription assistance from the SoonerCare Program. For instance children and pregnant women get free prescription benefits from the program. Can I transfer my child s previous medical expenses to SoonerCare if I qualify? No. Previous medical expenses incurred prior to qualifying for SoonerCare cannot be transferred to SoonerCare. Do my SoonerCare benefits include dental/vision care? Yes. Dental/Vision care are embodied in the SoonerCare program for certain qualified enrollees. What does the mental health program entail? It provides mental health, alcohol and other drug disorder treatment benefits to some members enrolled in the SoonerCare program. If I travel out of state temporary, can my medical insurance be used in my temporal place of abode/state? Depending on your specific circumstances, it could be possible to reimburse providers outside the state where one might be temporary domiciled. Can I use my SoonerCare card to receive services at the Community Health Centers? Yes. Granted the Community Health Center is a contracted SoonerCare provider. I need to know more about the SoonerCare Program, who do I contact? Call the OHCA Sooner hotline at for more information about the program. 10

11 What does my medical insurance cover? SoonerCare offers varying health benefit packages to its qualified members. Depending on which program you qualify for, the benefits are varied, ranging from doctor s visit, hospitalization, prescription drug benefits, family planning, breast and cervical cancer screening and treatment and many more. You can also get more information at the OHCA website at: Do the SoonerCare benefits cover preventive health issues? Yes. If you are eligible for SoonerCare, preventive health issues are covered. I lost my medical card, how can I get a replacement? Call the OHCA hotline at and tell them about your lost card and you will be given assistance on how to get a replacement card. Do I have to make co-pay with the SoonerCare program? Depending on your categorical status, you may not have to make any copay. A typical example is children and pregnant women. However, other beneficiaries may have to make some form of copay for the services received. I receive Medicare, can I also apply for SoonerCare? Yes. Your status may qualify you as a dual eligible for both Medicare and Medicaid, based on your circumstance. I live in a rural area. How likely is it that I can find a provider? Very likely. Soonercare providers are available state-wide. If you have problem finding a provider, call Step 6: Citizenship and Identity I cannot find my citizenship verification documents, what should I do? Verification of citizenship/alien status and identity are required for all adults and children approved for SoonerCare. If you cannot find your verification documents, you may have to contact the appropriate agency for one. When the applicant/member is unable to obtain citizenship verification, a reasonable opportunity is afforded the applicant/member to obtain the evidence as well as assistance in doing so before taking action affecting the individual's eligibility. The reasonable opportunity time frame usually consists of 120 days. 11

12 The types of acceptable evidence that verify identity and citizenship include: (a) United States (U.S.) Passport; (b) Certificate of Naturalization issued by U.S. Citizenship & Immigration Services (USCIS) (Form N-550 or N-570); (c) Certificate of Citizenship issued by USCIS (Form N-560 or N-561); (d) Copy of the Medicare card or printout of a BENDEX or SDX screen showing receipt of Medicare benefits, Supplemental Security Income or disability benefits from the Social Security Administration; or (e) Tribal membership card or Certificate of Degree of Indian Blood (CDIB) card, with a photograph of the individual. Can I use my I-94 (USCIS Arrival-Departure Record) for eligibility verification? In some cases yes. If you are still within your visa status as an eligible alien, then your I- 94 Arrival-Departure slip may serve as a verification document. For how long does one have to live in OK to gain OK Residency? To be eligible for SoonerCare services, the applicant must be residing in the State of Oklahoma with intent to remain at the time the medical service is received. A durational residence requirement is not imposed. (1) Temporary absence from the state, with subsequent returns to the state, or intent to return when the purposes of the absence have been accomplished, does not interrupt continuity of Oklahoma residence. (2) Oklahoma residence does not include transients or visitors passing through the state but does not preclude persons who do not have a fixed address if intent is established. (3) Intent to remain or return is defined as a clear statement of plans to remain or return in addition to other evidence and/or corroborative statements of others. I am not legally present but now pregnant. Can I get Sooner care for the baby and myself? Yes, your baby qualifies for SoonerCare on delivery as well as yourself during pregnancy and delivery. Your eligibility will end at the end of the month of delivery. I am illegal and disabled. Can I qualify for SoonerCare? No, you will not qualify for SoonerCare based on your disability. 12

13 Step 7: Provider Selection Who accepts SoonerCare? Can you send me a list of providers? There is a long list of providers for the SoonerCare program. This can be found at the My SoonerCare- Member Enrollment Home page on the tab Provider Directory. Here, you can find a list of providers arranged by state and county of resident. You can also get information of providers from the OHCA office at Who is my provider? I want to change my provider, how do I go about it? You can change your provider anytime by logging on to your SoonerCare account and effect the necessary changes. You will have to choose your provider from the provider list depending on where you live. You can also call the OHCA at My provider is located far away from where I live, how can I get transportation assistance to reach him? SoonerRide provides free non-emergency transportation to and from SoonerCare covered appointments within 45 miles radius. You must call at least three business days before your appointment to arrange for your ride. You can schedule your ride by calling toll-free (877) and TDD (800) during these hours: 7 a.m. to 6 p.m. Monday through Friday; and 7 a.m. to 6 p.m. Saturday. Where do I go for pregnancy test? You can go for pregnancy test at any licensed SoonerCare contracted medical provider. Documentation of pregnancy must be from the medical provider and should include date of expected delivery. There is also testing at the state health department clinics, Planned Parenthood, Pregnancy Crisis Center or call the Oklahoma Health Care Authority at Step 8: Results What is the status of my application? If you do complete your application online, you will be provided with the result immediately on completion. However, if you submit a paper application, it will take up to 20 days for the DHS staff to get back to you with the results. What if I discover there s an error but I ve already submitted the application? You should log back into the system and enter the correct information. 13

14 If I m sending the verification document to OHCA, do I still need to complete the verification page? Yes, the verification page needs to be completed.. How long does it take to get results of a paper-submitted application? If all documentations and verifications are submitted with your application, it will take up to 20 days for the DHS staff to get back to you with the results. Why was my application denied? Applications are denied due to a number of reasons. It could be that you did not satisfy one or more of the requirements of the program you applied for. Call the OHCA for explanation. What should I do if the client is denied and says they want to file for a hearing? In such a case, one should fill out and file a grievance form with the OHCA. After an application is denied, when can I re-apply? There is no waiting period to re-apply after the initial application is denied. All you need to do is to make sure you fulfill all the requirements of the program in your next application. Can you recommend any other agency where I can seek medical insurance? You may want to contact agencies such as the Oklahoma State Department of Health, Oklahoma Department of Human Services, and the Oklahoma Health Care Authority for more information about what you may be eligible for. There are many rules that govern who is eligible for medical assistance and there are many other factors that can affect your eligibility. They include age, disability, pregnancy family size and income. You won't know for sure until you fill out an application and talk to someone. Other alternatives available to you may include the Insure Oklahoma program of the OHCA, the high-risk pool insurance, Community Health Centers as well as local charitable mission clinics. 14