Oklahoma Medicaid (SoonerCare) Long-Term Care Application Packet

OKLAHOMA MEDICAID (SOONERCARE) LONG-TERM CARE APPLICATION PACKET

TABLE OF CONTENTS

1. Cover Letter to OHCA / DHS
2. Applicant Identifying Information
3. Program Selection (NF Medicaid / ADvantage Waiver / SSI-Related)
4. Income Schedule and Income-Cap Determination
5. Resource (Asset) Schedule
6. Spousal Impoverishment Calculations
7. Homestead and Real Property Treatment
8. 60-Month Look-Back Disclosures and Transfer Analysis
9. Miller Trust / Qualified Income Trust Cover Sheet
10. Spend-Down Plan
11. Authorized Representative Designation
12. Medical Necessity / Level-of-Care Documentation
13. Verification and Signature
14. Document Index
15. Oklahoma Practice Notes
16. Sources and References

1. COVER LETTER TO OHCA / DHS

Date: [__/__/____]

Oklahoma Health Care Authority
4345 N. Lincoln Blvd.
Oklahoma City, OK 73105

Oklahoma Human Services — Adult and Family Services
[LOCAL COUNTY DHS OFFICE ADDRESS]

Re: Application for SoonerCare Long-Term Care Benefits
Applicant: [APPLICANT FULL NAME]
SSN: [XXX-XX-____]
Date of Birth: [__/__/____]
Program Requested: ☐ Nursing Facility Medicaid ☐ ADvantage Waiver ☐ ABD/SSI-Related

To Whom It May Concern:

Enclosed please find the application packet of [APPLICANT FULL NAME] for SoonerCare Long-Term Care benefits administered by the Oklahoma Health Care Authority and Oklahoma Human Services. The packet includes:

• Form 08MA001E (or successor) — SoonerCare application;
• Form ADv-9 / UCAT III request — for ADvantage Waiver applicants;
• Verifications of income, resources, citizenship, identity, and Oklahoma residency;
• A Qualified Income Trust (Miller Trust) instrument and corresponding bank account documentation, where applicable;
• Authorization for release of medical information.

Please direct all correspondence to the undersigned Authorized Representative.

Respectfully,

[________________________________]

[ATTORNEY OR REPRESENTATIVE NAME]

[FIRM NAME] — Oklahoma Bar No. [####]

[ADDRESS / PHONE / EMAIL]

2. APPLICANT IDENTIFYING INFORMATION

Spouse (if applicable):

3. PROGRAM SELECTION

Select the SoonerCare LTC program for which the applicant is applying:

• ☐ Nursing Facility Medicaid — institutional care in a Medicaid-certified nursing facility. Requires Nursing Facility Level of Care (NFLOC).
• ☐ ADvantage Waiver (Home and Community-Based Services) — administered through OHCA and DHS Aging Services. Requires NFLOC and waitlist clearance. Contact Aging Services at 1-877-809-0035.
• ☐ PACE (Program of All-Inclusive Care for the Elderly) — where available.
• ☐ ABD / SSI-Related SoonerCare for community-residing aged, blind, or disabled individuals.
• ☐ Tefra / Qualified Disabled Working Individual / other: [________________________________]

Anticipated date of admission to facility or activation of services: [__/__/____]

4. INCOME SCHEDULE AND INCOME-CAP DETERMINATION

4.1 Applicant Gross Monthly Income

4.2 Income-Cap Test

If "Yes": A Qualified Income Trust (Miller Trust) under 42 U.S.C. § 1396p(d)(4)(B) is required. See Section 9.

If "No": No income trust required; document the calculation and proceed.

5. RESOURCE (ASSET) SCHEDULE

5.1 Countable Resources

5.2 Exempt / Non-Countable Resources

• ☐ Primary residence (subject to the $752,000 home-equity limit; intent-to-return statement attached)
• ☐ One automobile
• ☐ Household goods and personal effects
• ☐ Burial space / plot
• ☐ Irrevocable burial contracts and burial fund up to $1,500
• ☐ Term life insurance
• ☐ Cash value life insurance with combined face value $1,500 or less
• ☐ Property essential to self-support
• ☐ Special Needs Trust (d)(4)(A) / Pooled Trust (d)(4)(C)
• ☐ Other (specify): [________________________________]

6. SPOUSAL IMPOVERISHMENT CALCULATIONS

Complete this section only if the applicant is married and the spouse will remain in the community.

6.1 Snapshot Date

Date of first continuous period of institutionalization (the "Snapshot Date"): [__/__/____]

Total countable resources of the couple on Snapshot Date: $[________]

6.2 Community Spouse Resource Allowance (CSRA)

6.3 Minimum Monthly Maintenance Needs Allowance (MMMNA)

7. HOMESTEAD AND REAL PROPERTY TREATMENT

7.1 Homestead

7.2 Other Real Property

List all non-homestead real property in which the applicant or spouse holds any legal or beneficial interest:

8. 60-MONTH LOOK-BACK DISCLOSURES AND TRANSFER ANALYSIS

8.1 Look-Back Window

Application month: [__/__/____]

Look-back start date: [__/__/____] (60 months prior)

8.2 Disclosed Transfers

List every uncompensated or partially compensated transfer of assets by the applicant or spouse during the look-back window:

8.3 Penalty Period Computation

8.4 Exempt or Excluded Transfers (mark all that apply)

• ☐ Transfer to spouse (or to another for the sole benefit of spouse)
• ☐ Transfer to disabled child of any age
• ☐ Transfer to disabled individual under age 65 (sole benefit)
• ☐ Transfer to (d)(4)(A), (d)(4)(B), or (d)(4)(C) trust for sole benefit of disabled individual under age 65
• ☐ Caregiver-child exception (home only) — child resided in home at least 2 years and provided care that delayed institutionalization
• ☐ Sibling-with-equity-interest exception (home only)
• ☐ Transfer for fair market value (full consideration)
• ☐ Transfer for purpose other than to qualify for Medicaid (rebuttal documentation attached)
• ☐ Hardship waiver requested (attach documentation)

9. MILLER TRUST / QUALIFIED INCOME TRUST COVER SHEET

Attached:

• ☐ Executed Miller Trust instrument
• ☐ Trustee acceptance / fiduciary bond (if any)
• ☐ Bank documentation establishing dedicated trust account
• ☐ Direct-deposit authorizations for assigned income
• ☐ Distribution worksheet showing PNA, MMMNA, premiums, and patient liability

10. SPEND-DOWN PLAN

If countable resources exceed the program limit, attach a written, dated spend-down plan documenting permissible expenditures. Permissible categories include:

• ☐ Payment of legitimate, pre-existing debts of the applicant or spouse
• ☐ Medical and dental expenses (including unpaid invoices)
• ☐ Home repairs, accessibility modifications, and necessary maintenance to homestead
• ☐ Replacement of vehicle with a single suitable automobile
• ☐ Pre-paid irrevocable burial contracts (any amount; verify it is irrevocable and itemized)
• ☐ Burial fund up to $1,500
• ☐ Personal effects, household goods, and clothing
• ☐ Annuity meeting DRA-compliant requirements (state remainder beneficiary, irrevocable, non-assignable, actuarially sound, equal periodic payments)
• ☐ Conversion to exempt resources (e.g., paying down mortgage on homestead)
• ☐ Funding of (d)(4)(A) Special Needs Trust for disabled spouse or disabled child

For each line, attach receipts, contracts, invoices, and bank records. Avoid any expenditure without full and adequate consideration; otherwise it will be analyzed as a transfer under Section 8.

11. AUTHORIZED REPRESENTATIVE DESIGNATION

I, [APPLICANT NAME], designate the following individual as my Authorized Representative under Okla. Admin. Code § 317:35-5-25 and 42 C.F.R. § 435.923 to act on my behalf in all matters relating to this SoonerCare application, including renewals and appeals:

Signature of applicant (or legal representative): [________________________________]

Date: [__/__/____]

12. MEDICAL NECESSITY / LEVEL-OF-CARE DOCUMENTATION

For Nursing Facility Medicaid or ADvantage Waiver, the applicant must meet Nursing Facility Level of Care (NFLOC).

• ☐ Form LTC-300R / Long-Term Care Authorization request submitted
• ☐ UCAT III (Uniform Comprehensive Assessment Tool, Part III) requested or completed
• ☐ Physician statement of medical condition and necessity
• ☐ MDS (Minimum Data Set) for facility residents, where applicable
• ☐ List of current diagnoses, medications, and ADL/IADL deficits

Treating physician: [________________________________]

Facility (if applicable): [________________________________]

Anticipated NFLOC determination date: [__/__/____]

13. VERIFICATION AND SIGNATURE

I declare under penalty of perjury under the laws of the State of Oklahoma that the foregoing application and all attachments are true, correct, and complete to the best of my knowledge. I understand that knowingly providing false information may result in denial of benefits, recoupment, civil penalty, and criminal prosecution under 56 O.S. § 1005 and federal law.

[________________________________]

[APPLICANT NAME] (or Authorized Representative)

Date: [__/__/____]

State of Oklahoma, County of [________]

Sworn to and subscribed before me this [____] day of [_______________], 20[____].

[________________________________]

Notary Public — My Commission Expires: [_______________]

14. DOCUMENT INDEX

The following supporting documents are submitted with this packet:

• ☐ Photo identification (driver license / state ID / passport)
• ☐ Social Security card
• ☐ Birth certificate / proof of citizenship
• ☐ Medicare card (front and back)
• ☐ Marriage certificate / divorce decree / death certificate of spouse
• ☐ Proof of Oklahoma residency (utility bill, lease, deed)
• ☐ Award letters for SS, SSI, VA, pensions
• ☐ Three (3) most recent pay stubs (if working)
• ☐ Five (5) years of bank statements for every account
• ☐ Brokerage / retirement account statements (5 years)
• ☐ Deeds and most recent mortgage statements
• ☐ Vehicle titles
• ☐ Life insurance policies (declaration page and current cash-value statement)
• ☐ Burial contracts / pre-need agreements
• ☐ Health insurance policies
• ☐ Existing trusts, powers of attorney, advance directives
• ☐ Tax returns (3 years)
• ☐ Miller Trust / QIT instrument and bank records (if applicable)
• ☐ Transfer documentation for any disclosed transfers (deeds, gift letters, contracts, appraisals)
• ☐ Hardship waiver request and supporting documentation (if applicable)

15. OKLAHOMA PRACTICE NOTES

• Single state agency vs. eligibility worker. OHCA is the federal "single state agency." DHS Adult & Family Services performs the eligibility determination for ABD and LTC populations. Communications, requests for verification, and notices typically come from DHS; OHCA controls policy, the State Plan, and waivers.
• Income-cap state. Oklahoma is one of the income-cap states. The Miller Trust under 42 U.S.C. § 1396p(d)(4)(B) is non-optional once income exceeds 300% of the SSI FBR. Many denials trace to (a) failing to fund the trust on time, (b) depositing resources rather than income, (c) failing to name the State of Oklahoma as residual beneficiary, or (d) drafting the trust as revocable.
• Look-back and penalty divisor. The federal 60-month look-back applies. The penalty divisor is the average statewide private-pay daily nursing facility cost × 30 and is published in OHCA Appendix C-1. Verify the current divisor before computing any penalty period.
• Estate recovery. Oklahoma pursues estate recovery under 56 O.S. § 162 and Okla. Admin. Code § 317:35-7-65 against the probate estate of recipients age 55 and older for LTC services and certain related care. Plan accordingly using non-probate transfer mechanisms (TOD/POD, joint tenancy, transfer-on-death deed under 58 O.S. § 1251 et seq.) where lawful.
• Transfer-on-death deed. A properly recorded TOD deed under the Nontestamentary Transfer of Property Act passes the homestead outside probate and outside the current Oklahoma estate-recovery definition; consult counsel on current OHCA recovery scope before relying.
• DRA-compliant annuities. An applicant or spouse may convert excess countable resources into a DRA-compliant annuity that names the State of Oklahoma as the first remainder beneficiary up to the amount of medical assistance paid.
• ADvantage waitlist. ADvantage Waiver slots are limited. Apply early through DHS Aging Services (1-877-809-0035). Waitlist position does not preserve eligibility — the applicant must meet financial and medical criteria when a slot becomes available.
• Fair hearings. Adverse decisions are appealable to OHCA Legal Division within the time stated on the notice (usually 20 days for a hearing that maintains aid pending). Okla. Admin. Code § 317:2-1-2 governs.
• Time-sensitive funding. A Miller Trust is effective only for the months in which excess income is properly deposited. Direct deposits should be set up before the application's "month of need."

16. SOURCES AND REFERENCES

• 42 U.S.C. § 1396p (Medicaid transfers, liens, trusts) — https://www.govinfo.gov/
• 42 U.S.C. § 1396r-5 (Spousal impoverishment)
• 56 O.S. §§ 1010, 162 (Oklahoma Medical Assistance and estate recovery)
• 58 O.S. § 1251 et seq. (Nontestamentary Transfer of Property Act — TOD deed)
• Okla. Admin. Code Title 317 (OHCA) — https://oklahoma.gov/ohca/policies-and-rules.html
• Okla. Admin. Code Title 340 (DHS) — https://oklahoma.gov/okdhs/library/policy.html
• OHCA Appendix C-1, Maximum Income, Resource, and Payment Standards — https://oklahoma.gov/content/dam/ok/en/okdhs/documents/searchcenter/okdhsformresults/c-1.pdf
• OHCA SoonerCare — https://oklahoma.gov/ohca.html
• OHCA ADvantage Waiver — https://oklahoma.gov/ohca/individuals/programs/advantage-waiver-program.html
• DHS Aging Services / ADvantage — https://oklahoma.gov/okdhs/services/cap/advantage-services.html
• DHS Adult & Family Services — https://oklahoma.gov/okdhs/services/afs.html
• Legal Aid Services of Oklahoma — Medicaid resources — https://oklaw.org/
• 2026 Medicaid Eligibility Projections — https://www.medicaidplanningassistance.org/medicaid-eligibility-2026/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Medicaid figures, transfer divisors, and policy interpretations change frequently. An attorney licensed in Oklahoma must review and customize this document, and verify current OHCA / DHS thresholds, before any reliance.