SoonerCare (Medicaid) Services

SoonerCare (Medicaid)

Eligibility

To be eligible for these services, the individual must:   

AND meet category-specific criteria:             

Children under the age of 19 and pregnant women:

Adults with children under the age of 19:

Adults who are 65 or older:

Adults or children who have blindness or another disability determination from SSA:

NOTE:  If you currently receive services from a waiver, you are eligible for SoonerCare services (if they are deemed medically necessary by OHCA) and do not have to apply.

Services Offered

Services offered may include (see glossary for definitions):

Click here for a complete list of services offered.

NOTE:  Only services deemed medically necessary by OHCA will be covered through
SoonerCare (Medicaid).

Application

If the person requesting benefits is over 65, or has blindness or another disability, contact your local Oklahoma Department of Human Services (DHS) office and ask to apply for SoonerCare (Medicaid). You will need to fill out the Request for Benefits form.

If not, you will need to fill out the SoonerCare Health Benefits Application. Visit okhca.org to enroll online, renew eligibility and update contact information. If you need assistance, call 1-800-987-7767.

You must have eligibility renewed each year.

Early and Periodic Screening, Diagnosis and Treatment (EPSDT)/
Child Health Services

Eligibility

To be eligible for these services, the individual must:    

Services Offered

Services offered may include:    

Click here for a complete list of services offered.

Application

Apply for SoonerCare (Medicaid). There is no separate EPSDT application form for this service. You must have eligibility renewed each year.

Personal Care Services

Eligibility

To be eligible for these services, a person of any age must:    

NOTE:  This service does not provide technical care, such as tracheotomy care, colostomy or urostomy care, transferring a person who cannot assist, etc.

Services Offered

Services offered may include assistance with:    

Application

Contact your local Oklahoma Department of Human Services (DHS) office and apply for SoonerCare (Medicaid). There is no separate application for Personal Care Services. A long-term care nurse will assess the needs of the applicant. Call 1-800-435-4711 for assistance with intake or screening. If you already are eligible for SoonerCare (Medicaid), call your local DHS office and ask to be referred to Personal Care Services. You must have eligibility renewed each year.

TEFRA
(Tax Equity and Fiscal Responsibility Act)

The purpose of TEFRA is to provide SoonerCare (Medicaid) services to children with physical or intellectual disabilities who would not typically qualify for Medicaid benefits because of their parents’ income or resources, so that they can remain at home.

Eligibility

To be eligible for these services, the child must:    

NOTE:  DHS determines financial eligibility. OHCA determines level of care, disability status and cost effectiveness. Children receiving TEFRA can still apply for DDS Home and Community Based Waivers. If a child who is receiving TEFRA is approved for a waiver, TEFRA services will be discontinued.

Services Offered

Services offered may include:    
All SoonerCare (Medicaid) services allowed under the Medicaid State Plan and EPSDT/Child Health Services, as long as they are approved by OHCA.

Application

The TEFRA application process involves a number of steps and two agencies – the Oklahoma Department of Human Services (DHS) and the Oklahoma Health Care Authority (OHCA).

Step 1: You must have an SSI (Supplemental Security Income) denial letter stating your family’s income is too high.
If you have never applied for SSI for your child, you must do so through the Social Security Administration (SSA). If SSA determines your child is ineligible because of your income, request a denial letter. This denial letter is a required part of your TEFRA application to determine your child’s financial eligibility. SSA may not make a disability determination if your child is denied based on income. If this happens, OHCA will make a disability determination later.

Step 2: Contact your local DHS office and request TEFRA services.
You will be asked to complete the Request for Benefits form first (this is not the TEFRA application). This form is a general application for a variety of services. You complete this simply to ensure that your child does not qualify for SoonerCare (Medicaid) under the normal income standards.

Step 3: Complete the TEFRA application, which is called the Physician Assessment for TEFRA.
If your DHS case worker determines your household income is too high for SoonerCare based on the information provided in the Request for Benefits form, he or she will process your application as TEFRA and count only the child’s income. You will then need to complete the TEFRA application, or Physician Assessment (TEFRA-1) form. To complete it, you will need to provide detailed information about your child’s medical needs and have your child’s physician complete some parts of the form to determine medical eligibility.

Step 4: Turn in your TEFRA application to your local DHS office.
When you do this, it is a good idea to ask for a time-stamped copy of each page of your completed application.

Step 5: Your DHS case worker will send your application to OHCA.
OHCA will determine your child’s disability status and level of care. You may be contacted by your case worker if more information is needed.

Step 6: An OHCA nurse will visit your home.
Once disability and level of care decisions have been made, an OHCA nurse will set up a time to visit your home to ensure that your child can be adequately cared for in the home (in other words, to make sure that it is appropriate and safe to care for your child in the home instead of a hospital or other facility).

Step 7: OHCA informs your DHS case worker if your child is eligible for TEFRA.

Step 8: If OHCA determines your child is eligible, you will receive a letter and a SoonerCare card for your child in the mail. OHCA staff will contact you to provide you with more information about the TEFRA program.

More detailed information about the application is available by clicking the links below:

Parent Guide for TEFRA – provides more specific information about the application process, including what information and documentation you and your child’s physician will need to provide:

TEFRA checklist – provides a list of information and documentation you will need to provide to apply for TEFRA

You also can call 1-800-987-7767 or visit www.okhca.org for assistance.