Oklahoma Medicaid (SoonerCare) ADvantage Waiver Program

Last updated: October 20, 2021

 

Overview of Oklahoma’s ADvantage Waiver Program

Oklahoma’s ADvantage Waiver Program provides home and community-based services (HCBS) for elderly and disabled Oklahoma residents who are at risk of institutionalization (being placed in a nursing home). Provided long-term services and supports are dependent on the specific needs and circumstances of the program participant. Examples of potential benefits include in-home personal care assistance, assisted living services, adult day health care, personal emergency response systems, and home accessibility and safety modifications. This program also provides services for persons who currently reside in a nursing home facility, but can return home with care assistance and supports.

Personal care assistance offered under this program may be provided by licensed care workers or program participants have the option to self-direct their personal care services via Consumer Directed Personal Assistance Services and Supports (CD-PASS). CD-PASS is an option that allows the program participant to hire, manage, and fire the “personal services assistant” (caregiver) of their choosing. This may include a friend or relative, such as an adult child, niece, nephew, grandchild, or sibling. With the exception of very rare situations, a spouse cannot be hired as the caregiver. Program participants can select an “authorized representative” to assist with employer tasks. The authorized representative cannot be the same person as the paid caregiver. A financial management services agency handles the financial aspects of employment responsibilities such as tax withholding and caregiver payments.

 Medicaid-funded personal care assistance can also be provided via Oklahoma’s State Plan Personal Care. Unlike the ADvantage Waiver Program, a nursing facility level of care is not required.

Program participants can reside in their own home, the home of a friend or family member, or a Medicaid-approved assisted living residence. It is thought they cannot live in an adult foster care home.

The ADvantage Waiver Program is not an entitlement program, which means meeting eligibility requirements does not equate to immediate receipt of program benefits. Instead, the waiver has a limited number of participant enrollment slots, and when these slots are full, a waitlist for program participation forms.

The ADvantage Waiver Program is a 1915(c) Home and Community Based Services (HCBS) Medicaid waiver. Medicaid in Oklahoma is called SoonerCare.

 What are 1915(c) HCBS Medicaid Waivers?
Historically Medicaid only paid for long-term care in nursing homes. 1915(c) HCBS Medicaid Waivers allow states to offer benefits outside of these institutions. “HCBS” stands for “Home and Community Based Services. The goal of HCBS is to delay or prevent institutionalization and to that end, care may be provided in one’s home, the home of a relative, assisted living, or adult foster care / adult family living. Waivers can target specific groups who require a nursing home level of care and are at risk of institutionalization such as the elderly, disabled, or persons with Alzheimer’s. Waivers are not entitlements. This means that meeting eligibility criteria does not guarantee receipt of benefits, as there are a limited number of slots for program participants.

 

Benefits of the ADvantage Waiver Program

Follows is a list of benefits available via the ADvantage Waiver Program. An individual care plan will determine which services and supports a program participant will receive.

– Adult Day Health Care
– Advanced Supportive / Restorative Care
– Assisted Living Services – i.e., personal care, housekeeping, laundry, intermittent nursing care
– Case Management
– Consumer-Directed Personal Assistance Services and Supports (CD-PASS)
– Home Delivered Meals
– Home Modifications – i.e., grab bars, ramps, widening of doorways
– Hospice Care
– Personal Care Assistance
– Personal Emergency Response Systems
– Prescription Medications
– Respite Care – short-term in-home and nursing facility care to alleviate a primary caregiver
– Skilled Nursing
– Specialized Medical Equipment / Supplies
– Therapy Services – physical, speech, respiratory, and occupational
– Transitional Case Management – to assist persons transitioning from an institution back home or into the community

While services can be provided in assisted living residences, the cost of room and board is not covered by the ADvantage Waiver Program.

 

Eligibility Requirements for the ADvantage Waiver Program

The ADvantage Waiver Program is for OK residents at risk of nursing home placement who are elderly (65+) or disabled (21 to 64). Developmentally disabled adults cannot have a cognitive impairment related to their disability nor can they be intellectually disabled. Disabled program participants can continue to receive services via the ADvantage Waiver upon turning 65. Additional eligibility criteria are as follows below.

 The American Council on Aging provides a Medicaid eligibility test for Oklahoma seniors that require ongoing assistance. Start here

 

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 300% of the Federal Benefit Rate (FBR), which increases on an annual basis in January. In 2021, an applicant, regardless of marital status, can have a monthly income up to $2,382. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $2,382 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of his/her spouse. Furthermore, monthly income from the applicant spouse can be transferred to the non-applicant spouse as a spousal income allowance, also called a monthly maintenance needs allowance. The maximum amount that can be transferred is $3,260 / month (effective Jan. 2021 – Dec. 2021) and is intended to ensure the non-applicant spouse has a minimum monthly income of this amount. Non-applicant spouses who have their own income equal to or greater than $3,260 / month are not entitled to a spousal income allowance.

Assets
In 2021, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, each spouse can have up to $2,000 in assets. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are limited, though the non-applicant spouse is allocated a larger portion of the assets to prevent spousal impoverishment. (Unlike with income, Medicaid considers the assets of a married couple to be jointly owned). In this case, the applicant spouse can retain up to $2,000 in assets and the non-applicant spouse can keep up to $130,380. This larger allocation of assets to the non-applicant spouse is called a community spouse resource allowance.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a look back rule and violating it results in a penalty period of Medicaid ineligibility.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our spend down calculator.  

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for eligibility purposes, OK Medicaid considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $603,000. Home equity interest is the current value of the home minus any outstanding mortgage.
– A spouse lives in the home.
– The applicant has a permanently disabled or blind child living in the home.
– The applicant has a minor child (under 21) living in the home.

To learn more about the potential of Medicaid taking the home, click here.

 

Medical Criteria: Functional Need

An applicant must require a nursing facility level of care (NFLOC). For the ADvantage Waiver, the tool used to determine if this level of care need is met is the OHS Uniform Comprehensive Assessment Tool (UCAT) III. An applicant’s ability / inability to complete their activities of daily living (ADLs) and instrumental activities of daily living (IADLs) is strongly considered. Examples of ADLs and IADLs include bathing, personal hygiene, mobility, dressing, toileting, meal preparation, shopping for essentials, and housework. It is thought that persons with Alzheimer’s disease or a related dementia may be eligible for program services if NFLOC is met. However, a diagnosis of dementia in and of itself does not mean one will meet a NFLOC.

 For more information about long-term care Medicaid in Oklahoma, click here

 

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for OK Medicaid / SoonerCare. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

When persons have income over the limits, Miller Trusts, also called a qualified income trust can help. “Excess” income is deposited into the trust, no longer counting as income.

When persons have assets over the limits, trusts are an option. Irrevocable Funeral Trusts are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Another option are annuities, which turn countable assets into a stream of income. There are many alternative options when the applicant has assets over Medicaid’s limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid planners are educated in the planning strategies available in the state of Oklahoma to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, there are additional planning strategies that not only help one meet Medicaid’s financial criteria, but can also protect assets from Medicaid’s estate recovery program and for family as inheritance instead. These strategies often violate Medicaid’s 60-month look back rule, and therefore, should be implemented only with very careful planning and well in advance of the need for long-term care. However, there are some workarounds, and Medicaid planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.

 

How to Apply for Oklahoma’s ADvantage Waiver Program

Before You Apply

Prior to submitting an application for the Oklahoma ADvantage Waiver Program, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid eligibility test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.

Since the ADvantage Waiver is not an entitlement program, there may be a waitlist for program participation. This waiver is approved for a maximum of approximately 24,375 beneficiaries each year. In the case of a waitlist, an applicant’s access to a participant slot is based on the date of Medicaid waiver application.

 

Application Process

To apply for the ADvantage Waiver Program, applicants should contact the Medicaid Services Unit at 1-800-435-4711. Alternatively, persons can contact their county Oklahoma Department of Human Services office. Contact information can be found here. Applicants can also initiate the application process by completing an online application for in-home services here.

For additional information about the ADvantage Waiver Program, click here. Another option is to contact the OKDHS Aging Services Division at 405-521-2281. The Oklahoma Department of Human Services’ (OKDHS) Division of Aging Services administers the ADvantage Waiver Program.

 

Approval Process & Timing

The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further. Furthermore, as wait-lists may exist, approved applicants may spend many months waiting to receive benefits.

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