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OKDHS Home > Library > Policy > OAC 317 > Chapter 35. Medical Assistance for Adults and Children - Eligibility > 6. SoonerCare Health Benefits for Categorically Needy Pregnant Women and Families with Children > 38. Presumptive eligibility for pregnant women
317:35-6-38. Presumptive eligibility for pregnant women
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Revised 3-1-10

 

(a) Presumptive Eligibility (PE) is a limited period of SoonerCare eligibility for categorically needy pregnant women that is determined by a qualified provider.  Its purpose is to encourage pregnant women to receive adequate prenatal care in the earlier months of their pregnancy, and to ensure qualified providers of payment for the prenatal care.  The PE period precedes the SoonerCare eligibility determination and begins on the date a qualified provider makes a determination of presumptive eligibility.  The basis for the determination is preliminary information that the net family income of the pregnant woman does not exceed the standards on the OHCA website or the OKDHS form 08AX001E (Appendix C-1) (.pdf,  8 pp,  316 KB)  Schedule I, which are 185% of the Federal Poverty Level.

(b) Pregnant women are excluded from a resource test.  When a qualified provider has made this determination, the provider is required to notify the county office in the OHCA Eligibility Unit within five working days after the date of PE determination.  The OHCA Eligibility Unit does not make PE determinations.  When a PE determination is received, the worker determines SoonerCare eligibility using normal procedures.

  • (1) Qualified providers.  The determination that a provider is qualified to make a PE determination is made by the OHCA.  A listing of approved qualified providers is found on the OHCA website.  The OHCA Eligibility Unit must be sure a PE determination is made only by a qualified provider.
  • (2) Application and eligibility determination process for presumptive eligibility.  The OHCA Eligibility Unit supplies the qualified providers with the necessary forms and instructions to complete and correctly determine PE for pregnant women.
    • (A) The forms include the following:
      • (i) The SoonerCare Application.  This form must be completed at the PE determination and serves to gather information to complete PE determination and also to use for SoonerCare eligibility determination;
      • (ii) OHCA Form MA-PE-1 (08MA003E) (.pdf, 4 pp, 140 KB), Presumptive Eligibility Budget Sheet, which is completed by the qualified provider to verify pregnancy and provide income screening necessary to determine PE.  Instructions for completing the form and eligibility rules are included on the back of the form; and
      • (iii) OHCA Form MA-PE-2 (08MA020E) (.doc, 2 pp, 657 KB), Notice to Pregnant Women Regarding Presumptive Eligibility for SoonerCare, which is completed and given to the pregnant woman by the qualified provider.  It informs her whether she has been determined to be presumptively eligible or ineligible by the qualified provider.  It also contains information regarding the application process as well as a detailed list of what is needed to complete the SoonerCare application.
    • (B) After determining the pregnancy of the individual, the qualified provider determines financial eligibility.  OHCA Form MA-PE-1 (08MA003E) (.pdf, 4 pp, 140 KB) is completed to document the pregnancy and the financial eligibility.  If the qualified provider determines the individual meets PE requirements, OHCA Form MA-PE-2 (08MA020E) (.doc, 2 pp, 657 KB) is completed and given to the individual.  The originals of the SoonerCare Application form and OHCA Form MA-PE-1 (08MA003E) (.pdf, 4 pp, 140 KB) are sent to the OHCA Eligibility Unit.  They must be received within five working days after the date of the PE determination.
    • (C) If the individual is determined by the qualified provider to not meet PE requirements, the qualified provider completes OHCA Form MA-PE-2 (08MA020E) (.doc, 2 pp, 657 KB) and gives it to the individual.  The qualified provider also advises the individual she may be eligible for SoonerCare and refers her to the on line application or the OKDHS county office for SoonerCare eligibility determination.
    • (D) A PE determination may be made at any time during a pregnancy, even if there is an application pending.  Only one PE period will be granted during a pregnancy.
    • (E) Only a pregnant woman may be determined as PE.  No other household member may be certified as presumptively eligible.
  • (3) Household definition.  For purposes of this Section, the household is defined as the pregnant woman, her spouse or male acting in the role of the spouse, and her minor dependent children.  The unborn child(ren) is also included as a member(s) of the household.  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.
  • (4) Income computation.  The PE determination of the pregnant woman requires the provider to compute the total monthly income of the household as shown on the SoonerCare Application.  The total monthly income includes the earned and unearned income of all household members.  If the pregnant woman is a minor (under age 18) and lives with her parents, her parents' income must be included, regardless of the minor pregnant woman's marital status.  The income included in the PE determination is the total income received in the month that PE is determined by the qualified provider.  The household's total net income must be equal to or less than the standards on the OHCA website or the OKDHS Form 08AX001E (Appendix C-1) (.pdf,  8 pp,  316 KB), Schedule I, which are 185% of the Federal Poverty Level.
    • (A) Countable earned income is the gross earnings of each household member minus the AFDC work related expenses and paid dependent care expenses not to exceed the AFDC dependent care limits (see OAC 317:35-10).  Countable unearned income is the total unearned income of all household members.  The AFDC rule on unearned income exclusions is followed.
    • (B) The total countable net earned income plus the total countable unearned income is the total countable net income.  This total and the household size is compared to the standards on OHCA Form MA-PE-1 (08MA003E) (.pdf, 4 pp, 140 KB) to determine financial eligibility.
  • (5) Presumptive eligibility period.  Presumptive eligibility begins on the date a qualified provider determines the total countable monthly net income of a pregnant woman's household does not exceed the eligibility standard on the OHCA website or OKDHS Form 08AX001E (Appendix C-1) (.pdf,  8 pp,  316 KB), Schedule I.  Presumptive eligibility ends with (and includes) the earlier of:
    • (A) The day an eligibility or ineligibility determination is made; or
    • (B) The 45th day after the date on which the qualified provider made the PE determination (the 45 day count begins on the day following the eligibility determination date).
  • (6) Approval of presumptive eligibility.  When the OHCA Eligibility Unit  receives timely a completed PE certification, a case number, if needed, is assigned.  The PE certification is processed within five working days.  The applicant is notified of the PE determination by computer generated notice.  The notice also advises that the PE period expires 45 days from the date of the qualified provider's approval.  The case is automatically closed at the end of the 45 day period if a decision has not been made on the SoonerCare application. 
  • (7) Incomplete/incorrect presumptive eligibility forms.  Upon receipt of the SoonerCare Application and OHCA Form MA-PE-1 (08MA003E) (.pdf, 4 pp, 140 KB) from the qualified provider, the OHCA Eligibility Unit immediately screens them for completeness and correct determination.
    • (A) The SoonerCare Application for PE is considered incomplete if it is not filled out in its entirety, properly signed and dated.  OHCA Form MA-PE-1 (08MA003E) (.pdf, 4 pp, 140 KB) is considered incomplete if any response is omitted or if the form is not properly signed and dated.
    • (B) The presumptive eligibility determination is considered to be incorrect if the provider submitting the certification has not been determined to be a qualified provider by the OHCA.  The presumptive eligibility decision is also incorrect if the income computed by the qualified provider exceeds the allowable standard.
    • (C) When it is determined the PE certification is incomplete or incorrect, the original OHCA Form MA-PE-1 (08MA003E) (.pdf, 4 pp, 140 KB) and a copy of the SoonerCare application, are returned to the qualified provider.  The worker proceeds with the SoonerCare eligibility determination.  To maintain the original PE certification period, the qualified provider must correct and/or complete the forms and return them to the OHCA Eligibility Unit within the original five working days.  If this requirement is not met, an amended PE determination and PE determination date must be completed by the provider.
  • (8) Presumptive eligibility forms not received within five working days.  A qualified provider is required to provide the PE determination to the OHCA Eligibility Unit within five working days after the date of the PE determination.  The forms must be complete and correct as explained in paragraph (7) of this subsection.  Forms received on the sixth day (or later) after the PE determination date are returned to the qualified provider with a request for an amended PE determination and PE determination date.
  • (9) Erroneous payments and appeal rights.  When an individual is certified as presumptively eligible and a determination is made later that the individual is not eligible for SoonerCare, the PE period ends with the effective date of the SoonerCare application denial.  In this instance, the effective date of denial is the day following the date the ineligibility decision is made.
    • (A) If the ineligibility is not due to a misrepresentation by the applicant, any payments made are not considered to be erroneous.  If the ineligibility is due to the applicant withholding or misrepresenting information, any payments made are considered to be erroneous and a recipient overpayment is submitted to OKDHS State Office, FSS Overpayment Section.
    • (B) The applicant cannot appeal a PE determination made by a qualified provider or the expiration of the PE period (45 days).
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Last Updated:  11/21/2011
Oklahoma Department of Human Services
Street address: Sequoyah Memorial Office Building, 2400 N. Lincoln Blvd., Oklahoma City, OK 73105
Mailing address: P.O. Box 25352, Oklahoma City, OK 73125
(405) 521-3646
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