Oklahoma Medicaid (SoonerCare) State Plan Personal Care (SPPC)

Last updated: October 20, 2021

 

Overview of Oklahoma State Plan Personal Care

Oklahoma’s State Plan Personal Care (SPPC) Program is intended for elderly and disabled persons who require assistance with their daily living activities in order to live at home. Via SPPC, personal care attendants provide program participants assistance with their activities of daily living (ADLs) and instrumental activities of daily living (IADLs). This includes bathing, grooming, transitioning from one position to another, mobility, using the toilet, meal preparation, eating, laundry, shopping for essentials, and basic housecleaning.

Personal care assistance can be provided by a “personal care assistant” who works for a home care agency or program participants have the option to self-direct their own care and hire, manage, and fire an “individual personal care assistant” (IPCA). This participant-directed option allows friends and family members to be hired as paid caregivers, given they are 18+ years old, capable of the required tasks, and not legally responsible for the program participant. Unfortunately, spouses cannot be hired to provide care. The state handles the financial aspects of employment responsibilities, such as processing time sheets, withholding taxes, and issuing caregiver payments.

Program participants must live at home or the home of a loved one. They cannot live in an adult foster care home or an assisted living residence.

The SPPC Program is an entitlement. This means meeting the state’s Medicaid eligibility requirements guarantees one will receive benefits. Put differently, there is never a wait list to receive personal care attendant services.

State Plan Personal Care (SPPC) is part of Oklahoma’s regular state Medicaid program. Persons might hear SPPC informally called the Personal Care Program. The Medicaid Program in OK is called SoonerCare.

 Medicaid Waivers vs. State Plan Medicaid
While home and community based services (HCBS) can be provided via a Medicaid waiver or a state’s regular Medicaid plan, HCBS through Medicaid state plans are an entitlement. Put differently, meeting the program’s eligibility requirements guarantees an applicant will receive benefits. On the other hand, HCBS via Medicaid waivers are not an entitlement. Waivers have a limited number of participant enrollment slots, and once they have been filled, a waitlist for benefits begins. Furthermore, HCBS Medicaid waivers require a program participant require the level of care provided in a nursing home, while state plan HCBS do not always require this level of care.

 

Benefits of State Plan Personal Care

The SPPC Program provides program participants with assistance with daily living activities. Follows is a list of activities with which one might receive assistance.

– Bathing
– Basic Housecleaning
– Dressing / Undressing
– Eating
– Grooming
– Hair Care
– Errands – i.e., shopping for essentials, such as groceries
– Laundry
– Meal Preparation
– Mobility
– Skilled Nursing – assessment and development of care plan
– Toileting

 

Eligibility Requirements for State Plan Personal Care

SPPC is for OK state residents of any age, given they require assistance with their daily living activities. Additional eligibility criteria are as follows and is relevant for seniors 65+ years of age.

 The American Council on Aging provides a quick Medicaid eligibility test for seniors

 

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 100% of the Federal Poverty Level (FPL), which increases on an annual basis in January. As of 2021, the income limit for a single applicant is $1,073 / month. Married couples, regardless of if one or both spouses are applicants, can have a monthly income up to $1,452.

 While many home and community based services Medicaid programs allow a non-applicant spouse to retain a larger portion of a couple’s income and assets, the State Plan Personal Care Program does not. In contrast, Oklahoma’s ADvantage Waiver, which offers a variety of long-term services and supports, does allow a non-applicant spouse a monthly maintenance needs allowance from his/her applicant spouse and a community spouse resource allowance.

Assets
In 2021, the asset limit is $2,000 for a single applicant. For married couples, the asset limit is slightly higher at $3,000. This hold true whether one or both spouses are applicants.

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.

While there is a 60-month look back rule in which Medicaid checks past asset transfers of those applying for nursing home Medicaid or home and community based services via a Medicaid waiver, it is thought this is not relevant for the State Plan Personal Care Program. In other words, the look back period is not applicable.

 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 / SoonerCare considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has “intent” to return to the home.
– 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.

Unlike other OK Medicaid programs that offer long-term care, the SPPC does not have a home equity interest limit for home exemption. Home equity interest is the current value of the home minus any outstanding mortgage.
However, after the passing of the program beneficiary, Medicaid will try to recover the amount in which it paid for the individual’s care. This is done via the Medicaid estate recovery program. Often it is through the sale of the deceased beneficiary’s home that Medicaid is reimbursed. Learn more about the potential of Medicaid taking the home here.

 

Medical Criteria: Functional Need

Unlike with many Medicaid long-term care programs, a nursing facility level of care (NFLOC) is not required. In fact, applicants cannot require this high of a level of care, but they must have a functional need for personal care assistance. This is determined by utilizing the Uniform Comprehensive Assessment Tool (UCAT) Part III. To functionally qualify, one must require assistance with their activities of daily living (ADLs) and / or instrumental activities of daily living (IADLs). Areas of consideration include mobility, toileting, bathing/grooming, dressing, transferring (i.e., getting into the bathtub and standing up from sitting in a chair), eating, cleaning, laundry, and cooking. While it is thought that persons with Alzheimer’s disease or a related dementia can participate in this program, a diagnosis of dementia in and of itself does not mean one will meet the functional criteria.

 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.

Utilizing Miller Trusts, called Medicaid Income Pension Trusts in Oklahoma, is a common strategy used to lower an applicant’s monthly countable income for long-term care Medicaid eligibility. Essentially, “excess” income is deposited into the trust, no longer counting as income. However, it is thought Medicaid Income Pension Trusts are not permitted for applicants to become income-eligible for the SPPC Program.

When persons have assets over the limits, Irrevocable Funeral Trusts (IFTs) are an option. IFTs are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Persons can also “spend down” assets on home improvements (i.e., updating plumbing, replacing a water heater), home modifications (i.e., adding a first floor bedroom, addition of grab bars), and paying off credit cards and other debt. Annuities, in which a lump sum of cash is converted into a monthly income stream, is another option for turning countable assets into non-countable assets. There are many other options when the applicant has assets exceeding the 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 Oklahoma to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, while it is thought Medicaid’s 60-month look back rule does not apply to the State Plan Personal Care Program, it does apply to nursing home Medicaid and the ADvantage Waiver Program. As more extensive Medicaid-funded care might be required in the future, it is vital that one not violate the look back rule. Medicaid planning strategies should ideally only be implemented with 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 State Plan Personal Care

Before You Apply

Prior to submitting an application for State Plan Personal Care, applicants need to ensure they meet the eligibility criteria for OK Medicaid / SoonerCare. 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 need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, proof of income, previous bank statements, 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.

 

Application Process

To apply for State Plan Personal Care, 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. The application form, “Request for Benefits”, can be found here by typing “Request for Benefits” into the search engine, which is found half way down the page.

For additional information about State Plan Personal Care, click here. Persons can also contact the OKDHS Aging Services Division at 405-521-2281. The Oklahoma Department of Human Services (OKDHS) administers the State Plan Personal Care 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. 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.

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