Health Benefits

Health care is expensive. Billions of dollars are spent annually to cover the costs of medical care received by children and adults.

As you might expect, it’s impossible to provide coverage for everyone. In fact, you’ll routinely encounter people who have legitimate health needs yet do not meet the criteria for coverage under Oklahoma’s health care system. Part of your responsibility will be to assist those individuals in locating alternative methods of meeting their needs. The need itself doesn’t disappear just because our programs aren’t able to help.

The Oklahoma Health Care Authority (OHCA) was created in 1995 to administer the health care program in this state. DHS has responsibility for determining financial eligibility.

Health benefits are provided to two basic groups:

• Those who will need some type of nursing care or alternative care all their lives.
• Those who require either a medical or financial service for a set period of time.

Oklahoma also administers a State Supplemental Payment (SSP) which assists those who are over 65 years of age, disabled or blind. Many Oklahomans qualify for health benefit services, and though you will not be involved in the process of having to know the scope of medical services that are available, you will be responsible for interviewing those requesting health benefits so you can make a determination of their financial eligibility.

You may be asked, “Is my prescription going to be paid for?” or “Will this surgery be covered?” Since the Oklahoma Health Care Authority has the answers to those questions, you will need to refer your clients to that agency for answers. They may also call their HMO, if they are enrolled in one, their Primary Care Provider (PCP), or the health provider. They all have access to that information.

As mentioned earlier, your primary concern is financial eligibility. Before you can begin to gather the information you need to establish that, however, you must first determine the categorical relationship of each individual requesting health benefits.

Categorical Relationship

One of the requirements written into the law establishing health care benefits is that each person who is approved must first be classified according to one of the following categories:

• Aged
• Blind
• Disabled
• Pregnant
• Age 19 (TANF)
• Age 18 or under (TANF)
• Parent or caretaker relative of a deprived child (TANF)

Until you establish the appropriate category, you do not know what rules to apply for income and resources, and you cannot proceed further. Those rules change with each category.