Oklahoma Medicaid (SoonerCare) Long Term Care Programs, Benefits & Eligibility Requirements

Summary
Medicaid’s rules, benefits and name can all vary by state. In Oklahoma, Medicaid is called SoonerCare. This article focuses on Oklahoma Medicaid Long Term Care for seniors, which will pay for care in a nursing home, a beneficiary’s home and other settings through one of three programs – Nursing Home Medicaid, HCBS Waivers or ABD Medicaid. This is different than regular Medicaid, which is for financially limited people of all ages.

 

Oklahoma Medicaid Long Term Care Programs

Nursing Home / Institutional Medicaid

Oklahoma Medicaid, which is called SoonerCare, will cover the cost of long-term care in a nursing home for financially limited Oklahoma seniors who require a Nursing Facility Level of Care. Coverage includes payment for room and board, as well as all necessary medical and non-medical goods and services, such as:

  • Personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting)
  • Skilled nursing care
  • Physician’s visits
  • Prescription medication
  • Medication management
  • Mental health counseling
  • Social activities

Items not covered include a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example) and any care services not considered medically necessary.

Oklahoma Nursing Home Medicaid beneficiaries are required to give most of their income to the state to help cover care expenses. They are only allowed to keep a “personal needs allowance” (PNA) of $75/month, which can be spent on personal items such as clothes, snacks, books, haircuts, flowers, etc. They can also keep enough of their income to make Medicare premium payments if they are “dual eligible,” and enough to make any Medicaid-approved spousal income allowance payments to financially needy spouses who are not Medicaid applicants or recipients.

Oklahoma Nursing Home Medicaid is an entitlement. This means all qualified applicants are guaranteed by law, aka “entitled,” to receive benefits without wait. However, not all nursing homes accept Medicaid, and those that do may not have any available spaces when you or your loved one needs care. So, eligible applicants are guaranteed nursing home coverage without wait, but they are not guaranteed coverage in any facility they choose.

  A Nursing Home Alternative – Oklahoma Nursing Home Medicaid beneficiaries who want to leave their nursing home and return to living “in the community” can receive financial and functional help with that transition through Oklahoma’s Money Follows the Person program (MFP). This help can include paying for moving expenses, as well as long-term care services and supports in the new residence. MFP beneficiaries must be moving from a Medicaid-approved facility and into their own home, the home of a relative or a small group home with a maximum of four unrelated residents. In Oklahoma, MFP is also called Living Choice.

 

Home and Community Based Services (HCBS) Waivers

Oklahoma Home and Community Based Services (HCBS) Waivers will pay for long-term care services and supports that help financially limited Oklahoma seniors who require a Nursing Facility Level of Care remain, or return to, living in the community instead of living in a nursing home. The word “waiver” means something like voucher in this instance. Think of it as a voucher that will pay for long-term care services for Oklahoma seniors who live in their home, the home of a loved one or a Medicaid-approved assisted living residence. While Oklahoma HCBS Waivers may cover long-term care benefits in those settings, it will not pay for room and board costs such as mortgage payments, rent, facility fees, utility bills and food expenses.

The HCBS Waiver relevant to Oklahoma seniors is the ADvantage Waiver Program.

ADvantage Waiver Program
Oklahoma’s ADvantage Waiver Program provides long-term care services and supports to Oklahoma seniors who require a Nursing Facility Level of Care but live in their own home, the home a loved one or a Medicaid-approved assisted living residence. To determine if an ADvantage Waiver Program applicant requires a Nursing Facility Level of Care, Oklahoma uses the OHS Uniform Comprehensive Assessment Tool (UCAT) III. The ADvantage Waiver Program also provides support for SoonerCare beneficiaries who are in a nursing home but can return home with the long-term care benefits provided by the program.

ADvantage Waiver Program benefits include adult day care, skilled nursing care, case management, meal delivery, home modifications and personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and the Instrumental Activities of Daily Living (shopping, cooking, cleaning, scheduling, transportation, etc.). These benefits can be provided by licensed caregivers, or ADvantage Waiver Program participants have the option to self-direct their benefits through Consumer Directed Personal Assistance Services and Supports (CD-PASS). This allows program participants to select friends and family members to provide certain benefits, like care assistance with the Instrumental Activities of Daily Living. In most cases, spouses can not be hired as caregivers via CD-PASS for the ADvantage Waiver Program.

Unlike Nursing Home Medicaid, the ADvantage Waiver Program is not an entitlement. Instead, it has a limited number of enrollment spots (24,375 per year as of 2023). Once those spots are full, additional applicants are placed on a waitlist.

 

Aged, Blind, and Disabled Medicaid

Oklahoma’s Aged, Blind, and Disabled (ABD) Medicaid provides healthcare coverage and long-term care services and supports to financially limited Oklahoma residents who are aged (65 and over), blind or disabled and live in the community. ABD Medicaid can sometimes be referred to as regular Medicaid for seniors, but it should not be confused with the regular Medicaid that is available for financially limited people of all ages. ABD Medicaid is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive healthcare coverage without wait. Access to long-term care benefits via ABD Medicaid depends on the availability of funds, programs and caregivers in the area where the beneficiary lives.

Oklahoma ABD Medicaid beneficiaries who show a functional need for long-term care benefits can receive some of those benefits through the State Plan Personal Care (SPCC) Program or the Program of All-Inclusive Care for the Elderly (PACE).

1. State Plan Personal Care (SPPC) Program
Oklahoma’s State Plan Personal Care (SPPC) Program provides long-term care benefits to Oklahoma ABD Medicaid beneficiaries who live in their own home or the home of a loved one and require assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and/or the Instrumental Activities of Daily Living (shopping, cooking, cleaning, scheduling, transportation, etc.).

SPPC Program benefits are specifically designed to help with the Activities of Daily Living and the Instrumental Activities of Daily Living. These benefits can be delivered by a licensed caregiver provided by SoonerCare (Oklahoma Medicaid), or the SPPC Program participant can self-direct their care by selecting their own “individual personal care assistant,” as long as that person is 18+ years old, capable of the required tasks and not the legal guardian of the program participant. They can be a friend or a family member, but not a spouse.

The SPPC Program, like SoonerCare ABD Medicaid coverage itself, is an entitlement. This means that all eligible applicants are guaranteed by law to receive benefits.

2. Program of All-Inclusive Care for the Elderly (PACE)
Oklahoma residents who are age 55 or older and have ABD Medicaid can cover their medical, social service and long-term care needs with one comprehensive plan and delivery system using the Program of All-Inclusive Care for the Elderly (PACE). PACE program participants are required to need a Nursing Facility Level of Care, but they must live in the community. Oklahoma’s PACE programs can be used by people who are “dual eligible” for Medicaid and Medicare, and it will coordinate the care and benefits from those two programs into one plan. PACE also administers vision and dental care, and PACE day centers provide meals, social activities, exercise programs and regular health checkups and services to program participants. Oklahoma’s PACE programs are located in Oklahoma City (Valir PACE), Tahlequah (Cherokee Elder Care) and Tulsa (LIFE PACE). To learn more about PACE, click here.

 

Eligibility Criteria For Oklahoma Medicaid Long Term Care Programs

To be eligible for SoonerCare (Oklahoma Medicaid) a person has to meet certain financial and functional (medical) requirements. The financial requirements vary by the applicant’s marital status, if their spouse is also applying for Medicaid, and what program they are applying for – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers or Aged, Blind, and Disabled (ABD) Medicaid.

  Just For You: The easiest way to find the most current SoonerCare (Oklahoma Medicaid) eligibility criteria for your specific situation is to use our Medicaid Eligibility Requirements Finder tool.

 

Oklahoma Nursing Home Medicaid Eligibility Criteria

Financial Requirements
Oklahoma residents have to meet an asset limit and an income limit in order to be financially eligible for nursing home coverage through SoonerCare (Oklahoma Medicaid). For a single applicant in 2024, the asset limit is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.

The 2024 income limit for a single applicant is $2,829/month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income. However, Oklahoma Medicaid beneficiaries who reside in nursing homes must give most of their income to the state to help pay for the cost of care. They are only allowed to keep $75/month of their income as a “personal needs allowance,” and they are allowed to make Medicare premium payments if they are “dual eligible,” and they can make any allowable spousal income allowance payments to financially needy, non-applicant spouses.

For married applicants with both spouses applying, the 2024 asset limit for nursing home coverage through SoonerCare is a combined $4,000, and the income limit is a combined $5,658/month. For a married applicant with just one spouse applying, the 2024 asset limit is $2,000 for the applicant spouse and $154,140 for the non-applicant spouse, thanks to the Community Spouse Resource Allowance. The income limit is $2,829/month for the applicant, and the income of the non-applicant spouse is not counted.

  Plan Ahead: There are alternative pathways to eligibility for Oklahoma Nursing Home Medicaid applicants who don’t meet their financial limits, such as Medicaid Planning. However, applicants are not allowed to simply give away their assets in order to get under the asset limit. To make sure they don’t, Oklahoma has a Look-Back Period of five years. This means the state will look back into the previous five years of the Nursing Home Medicaid applicant’s financial records to make sure they have not given away assets.

Functional Requirements
The functional, or medical, criteria for Oklahoma Nursing Home Medicaid is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that is normally associated with a nursing home. Oklahoma uses the OHS Uniform Comprehensive Assessment Tool III to determine if applicants require a NFLOC. This tool takes into consideration an applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), as well as their cognitive abilities.

 

Oklahoma Medicaid Home and Community Based Services (HCBS) Waivers Eligibility Criteria

Financial Requirements
Oklahoma residents have to meet an an asset limit and an income limit in order to be financially eligible for Home and Community Based Services (HCBS) Waivers. For a single applicant in 2024, the asset limit for HCBS Waivers in Oklahoma is $2,000, which means they must have $2,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.

The 2024 income limit for HCBS Waivers in Oklahoma for a single applicant is $2,829 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc. COVID-19 stimulus checks and Holocaust restitution payments are not considered income.

For married applicants with both spouses applying, the 2024 asset limit for HCBS Waivers in Oklahoma is a combined $4,000, and the income limit is a combined $5,658/month. For a married applicant with just one spouse applying, the 2023 asset limit is $2,000 for the applicant spouse and $154,140 for the non-applicant spouse, thanks to the Community Spouse Resource Allowance. The 2024 income limit is $2,829/month for the applicant, and the income of the non-applicant spouse is not counted.

  Plan Ahead: There are alternative pathways to eligibility for Oklahoma HCBS Waivers applicants who don’t meet their financial limits, such as Medicaid Planning. However, applicants are not allowed to simply give away their assets in order to get under the asset limit. To make sure they don’t, Oklahoma has a Look-Back Period of five years. This means the state will look back into the previous five years of the HCBS Waivers applicant’s financial records to make sure they have not given away assets.

Functional Requirements
The functional, or medical, criteria for Home and Community Based Services (HCBS) Waivers through SoonerCare (Oklahoma Medicaid) is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that is normally associated with a nursing home. Oklahoma uses the OHS Uniform Comprehensive Assessment Tool III to determine if applicants require a NFLOC. This tool takes into consideration an applicant’s ability to complete the Activities of Daily Living (mobility, bathing, dressing, eating, toileting), as well as their cognitive abilities.

Oklahoma Aged, Blind, and Disabled Medicaid Eligibility Criteria

Financial Requirements
Oklahoma residents have to meet an asset limit and an income limit in order to be financially eligible for Aged, Blind, and Disabled (ABD) Medicaid through SoonerCare (Oklahoma Medicaid). For a single applicant, the asset limit as of April 1, 2024, is $9,430, which means they must have $9,430 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the How Medicaid Treats the Home section below for more details), and there are other non-countable assets, like Irrevocable Funeral Trusts and Medicaid Compliant Annuities.

The income limit for ABD Medicaid in Oklahoma for a single applicant as of April 1, 2024, is $1,255/month. Almost all income is counted (IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc.) other than COVID-19 stimulus checks and Holocaust restitution payments.

For married applicants as of April 1, 2024, the asset limit for Oklahoma’s ABD Medicaid is a combined $14,130, and the income limit is a combined $1,704/month. These limits are for married couples with both spouses applying and married couples with just one spouse applying.

  Plan Ahead: There are alternative pathways to eligibility for Oklahoma ABD Medicaid applicants who are over the asset limit and/or the income limit, such as Medicaid Planning. While Oklahoma has a Look-Back Period of five years for Nursing Home Medicaid and HCBS Waivers applicants to make sure they don’t give away their assets to get under the limit, the Look-Back Period does not apply to ABD Medicaid applicants. However, ABD applicants should be cautious about giving away their assets. They might eventually need Nursing Home Medicaid or HCBS Waivers, and those programs will deny or penalize the applicant for giving away assets.

Functional Requirements
The only functional requirement to receive basic healthcare coverage through Oklahoma ABD Medicaid is being aged (65 and over), blind or disabled. For ABD Medicaid applicants and beneficiaries who require long-term care services and supports, the state will administer an assessment of their ability to perform Activities of Daily Living (mobility, bathing, dressing, eating, toileting) and Instrumental Activities of Daily Living (which include shopping, cooking, housekeeping and medication management) to determine the kind of long-term care benefits the state will cover.

 

How Oklahoma Medicaid Treats the Home for Eligibility Purposes

One’s home is often their most valuable asset, and if counted toward Medicaid’s asset limit, it would likely cause them to be over the limit. However, in many situations the home is not counted against the asset limit:

  • If the applicant lives in their home and the home equity interest (the portion of the home’s equity value that the applicant owns minus any outstanding mortgage/debt) is less than $713,000 (as of 2024) then the home is exempt.
  • If the applicant’s spouse, minor child, or blind or disabled child of any age lives there, the home is exempt regardless of the applicant’s home equity interest, and regardless of where the applicant lives.
  • If none of the above-mentioned people live in the home, the home can be exempt if the applicant/beneficiary files an “intent to return” home and the home equity interest is at or below $713,000.

These rules apply to all three types of Medicaid, with one important exception – ABD Medicaid applicants can disregard the home equity limit. Value does not matter regarding their home’s exempt status. To learn more about the impact of home ownership on Medicaid eligibility, click here.

Oklahoma Medicaid Long Term Care applicants and recipients may also want to consider protecting their home (and other assets) from estate recovery. States are required by law to try and collect reimbursement for long-term care after the death of Medicaid recipients. They do this through their Medicaid Estate Recovery Programs (MERPs). The rules and regulations regarding estate recovery can vary greatly by state, but all states have a MERP. To learn more about the MERP in Oklahoma and how you can protect your home from it, click here.

 

Applying For Oklahoma Medicaid Long Term Care Programs

The first step in applying for SoonerCare (Oklahoma Medicaid) Long Term Care coverage is deciding which of the three Medicaid programs discussed above you or your loved one wants to apply for – Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers or Aged, Blind, and Disabled (ABD) Medicaid.

The second step is determining if the applicant meets the financial and functional criteria, also discussed above, for that Long Term Care program. Applying for SoonerCare coverage when not financially eligible will result in the application, and benefits, being denied.

During the process of determining financial eligibility, it’s important to start gathering documentation that clearly details the financial situation for the SoonerCare applicant. These documents will be needed for the official Medicaid application. Necessary documents may include tax forms, Social Security benefits letters, deeds to the home, proof of life insurance and quarterly statements for all bank accounts, retirement accounts and investments. For a complete list of documents you might need to submit with your Medicaid Long Term Care application, go to our Medicaid Application Documents Checklist.

After financial eligibility requirements are checked and double checked, documentation is gathered, and functional eligibility is clarified, Oklahoma seniors can apply for SoonerCare online at OKDHSLive. They can also apply through their local Department of Human Services office.

For step-by-step guides to applying for each of the 3 types of Medicaid Long Term Care, just click on the name: 1) Nursing Home Medicaid 2) HCBS Waivers 3) ABD Medicaid.

  Professional Help: Many seniors need support when it comes to Medicaid Long Term Care’s rules, benefits and application process. These are all complicated, constantly changing and vary by state. The best place to get help with Medicaid Long Term Care is through a professional like a Certified Medicaid Planner or an Elder Law Attorney.

 

Choosing an Oklahoma Medicaid Nursing Home

After being approved for nursing home coverage through SoonerCare (Oklahoma Medicaid), you or your loved one has to choose which Medicaid-accepting nursing home best meets your needs. Even though Medicaid nursing home coverage is an entitlement, not all nursing homes accept Medicaid, and those that do may not have any available beds. Finding the right facility can be a challenge, especially if you’re looking in a specific part of the state, but Oklahoma residents have more choices than most.

Oklahoma has about 300 nursing homes that take Medicaid, which ranks No. 22 on the list of states with the most nursing homes, but Oklahoma ranks No. 28 in terms of population. By comparison, Oregon and Oklahoma have roughly the same population (4.2 million for Oregon, 4 million for Oklahoma), but Oregon only has 123 nursing homes that accept Medicaid.

The nursing homes in Oklahoma are spread throughout the state. There are clusters of facilities around Oklahoma City (50) and Tulsa (41), but after that they are more evenly distributed. Residents in some Oklahoma communities may regularly cross the state line for business and personal reasons, including healthcare, but Medicaid coverage does not cross state lines. So, someone with SoonerCare would not be covered for stays in nursing homes in Fayetteville or Fort Smith, Arkansas, even if facilities in those places are convenient or well-suited for the Oklahoma resident.

 TOOLS: To find and compare nursing homes, Oklahoma residents can use Nursing Home Compare, which is a search tool administered by the Centers for Medicare & Medicaid Services (CMS) that has information on more than 15,000 nursing homes across the country.

When you’ve found nursing homes that meet your needs and accept Medicaid, you can start comparing them, if you have multiple options. The search on Nursing Home Compare can be filtered by staffing, health inspections, quality measures and overall rating, which can be a good place to start. The healthcare professionals who work with you are another great source of information. And you can contact your local Area Agency on Aging to find out more information about nursing homes in Oklahoma.

After doing some research, you or someone you trust should visit any nursing homes you’re considering before making a final decision. Call first to make an appointment for the visit, and arrive with a list of questions, like: How does the facility handle dental and vision care? Does it offer social activities? What is the food like? Who are the staff doctors? CMS has a comprehensive “Nursing home checklist” you can use to evaluate a nursing home while visiting.

CMS data collected from 2019-2022 shows that Oklahoma nursing homes are on par with the national averages when it comes to health standards, fire safety, resident-to-staff ratio and overall well-being of residents.