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OREGON HEALTH AUTHORITY, DIVISION OF MEDICAL ASSISTANCE PROGRAMS




 

DIVISION 200
OFFICE OF CLIENT AND COMMUNITY
SERVICES MEDICAL PROGRAMS
410-200-0010
Overview
These rules, OAR 410-200-0010 through
0510, describe eligibility requirements for the Office of Client and Community Services
(OCCS) medical programs.
Stat. Auth.: ORS 411.402, 411.404 &
413.042
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231,
411.447, 414.534, 414.536 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0015
General Definitions
(1) “Action” means a termination,
suspension, denial, or reduction of Medicaid or CHIP eligibility or covered services.
(2) “Address Confidentiality
Program (ACP)” means a program of the Oregon Department of Justice that provides
a substitute mailing address and mail forwarding service for ACP participants who
are victims of domestic violence, sexual assault, or stalking.
(3) “AEN” means
Assumed Eligible Newborn (OAR 410-200-0115).
(4) “Affordable Care
Act” means the Patient Protection and Affordable Care Act of 2010 (Pub. L.
111–148), as amended by the Health Care and Education Reconciliation Act of
2010 (Pub. L. 111–152), as amended by the Three Percent Withholding Repeal
and Job Creation Act (Pub. L. 112–56).
(5) “Agency”
means the Oregon Health Authority, Department of Human Services, and Cover Oregon.
(6) “American Indian
and Alaska Native income exceptions” means:
(a) Distributions from Alaska
Native Corporations and Settlement Trusts;
(b) Distributions from any
property held in trust, subject to federal restrictions, located within the most
recent boundaries of a prior federal reservation or otherwise under the supervision
of the Secretary of the Interior;
(c) Distributions and payments
from rents, leases, rights of way, royalties, usage rights, or natural resource
extraction and harvest, including farming, from:
(A) Rights of ownership or
possession in any lands described in section (b) of this part; or
(B) Federally protected rights
regarding off-reservation hunting, fishing, gathering, or usage of natural resources;
(d) Distributions resulting
from real property ownership interests related to natural resources and improvements:
(A) Located on or near a
reservation or within the most recent boundaries of a prior federal reservation;
or
(B) Resulting from the exercise
of federally-protected rights relating to such real property ownership interests;
(e) Payments resulting from
ownership interests in or usage rights to items that have unique religious, spiritual,
traditional, or cultural significance or rights that support subsistence or a traditional
lifestyle according to applicable tribal law or custom;
(f) Student financial assistance
provided under the Bureau of Indian Affairs education programs.
(7) “Applicant”
means an individual who is seeking an eligibility determination for themselves or
someone for whom they are applying through an application submission or a transfer
from another agency, insurance affordability program, or the FFM.
(8) “Application”
means:
(a) The single streamlined
application for all insurance affordability programs developed by Cover Oregon and
the Authority or the FFM; or
(b) An application designed
specifically to determine eligibility on a basis other than the applicable MAGI
standard, submitted by or on behalf of the individual who may be eligible or is
applying for assistance on a basis other than the applicable MAGI standard,
(9) “APTC” means
advance payments of the premium tax credit, which means payment of the tax credits
specified in section 36B of the Internal Revenue Code (as added by section 1401
of the Affordable Care Act) that are provided on an advance basis to an eligible
individual enrolled in a QHP through an Exchange in accordance with sections 1402
and 1412 of the Affordable Care Act.
(10) “Assumed eligibility”
means an individual is deemed to be eligible for a period of time based on receipt
of another program benefit or because of another individual’s eligibility.
(11) “Authorized Representative”
means an individual or organization that acts on behalf of an applicant or beneficiary
in assisting with the individual’s application and renewal of eligibility
and other on-going communications with the Agency (OAR 410-200-0111).
(12) “Beneficiary”
means an individual who has been determined eligible and is currently receiving
OCCS medical program benefits, Aging and People with Disability medical program
benefits, or APTC.
(13) “BRS” means
Behavioral Residential Services.
(14) “Budget Month”
means the calendar month from which financial and nonfinancial information is used
to determine eligibility.
(15) “Caretaker”
means a parent, caretaker relative, or non-related caretaker who assumes primary
responsibility for a child’s care.
(16) “Caretaker Relative”
means a relative of a dependent child by blood, adoption, or marriage with whom
the child is living who assumes primary responsibility for the child’s care,
which may but is not required to be indicated by claiming the child as a tax dependent
for federal income tax purposes and who is one of the following:
(a) The child’s father,
mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother,
stepsister, uncle, aunt, first cousin, nephew, or niece;
(b) The spouse of the parent
or relative even after the marriage is terminated by death or divorce;
(c) An individual described
in this section who is a relative of the child based on blood, including those of
half-blood, adoption, or marriage.
(17) “CAWEM”
means Citizen/Alien-Waived Emergency Medical, which is Medicaid coverage for emergency
medical needs for clients who are not eligible for other medical programs solely
because they do not meet citizenship and alien status requirements (OAR 410-200-0240).
(18) “CAWEM Prenatal”
means medical services for pregnant CAWEM beneficiaries.
(19) “Child”
means an individual including minor parent, under the age of 19. Child does not
include an unborn. Child includes a natural or biological, adopted, or step child.
(20) “Children’s
Health Insurance Program” also called “CHIP” means Oregon medical
coverage under Title XXI of the Social Security Act.
(21) “Citizenship”
includes status as a “national of the United States” defined in 8 U.S.C.
1101(a) (22) that includes both citizens of the United States and non-citizen nationals
of the United States.
(22) “Claim”
means a legal action or a demand by, or on behalf of, an applicant or beneficiary
for damages for or arising out of a personal injury that is against any person,
public body, agency, or commission other than the State Accident Insurance Fund
Corporation or Worker’s Compensation Board.
(23) “Claimant”
means an individual who has requested a hearing or appeal.
(24) “Code” means
Internal Revenue Code of 1986 as amended.
(25) “Combined eligibility
notice” means an eligibility notice that informs an individual, or multiple
family members of a household when feasible, of eligibility for each of the insurance
affordability programs and enrollment in a qualified health plan through Cover Oregon
for which a determination or denial was made by Cover Oregon, the Authority, or
the FFM.
(26) “Community partner”
means all external entities that partner with Cover Oregon or the Authority and
enter into formal agreement with the Authority to conduct outreach or enrollment
assistance, whether or not they are funded or compensated by Cover Oregon or the
Authority. Insurance agents are not considered community partners.
(27) “Coordinated content”
means information included in eligibility notice regarding the transfer of the individual’s
or household’s electronic account to another insurance affordability program
for a determination of eligibility.
(28) “Cover Oregon”
means the Oregon Health Insurance Exchange Corporation.
(29) “Custodial Parent”
means, for children whose parents are divorced, separated, or unmarried, the parent
for whom:
(a) If living with one parent,
a court order or binding separation, divorce, or custody agreement establishes physical
custody controls; or
(b) If living with one parent
and there is no such order or agreement described in section (a), or in the event
of a shared custody agreement, the custodial parent is the parent with whom the
child spends most nights;
(c) If a child does not live
with either parent, the parent who claims the child as a tax dependent is treated
as the custodial parent for the purposes of OCCS medical program eligibility.
(30) “Date of Request”
means the earlier of:
(a) The date the request
for medical benefits is received by the Agency, the FFM, or a community partner;
or
(b) The date the applicant
received a medical service, if the request for medical benefits is received by midnight
of the following business day.
(31) “Decision notice”
means a written notice of a decision made regarding eligibility for an OCCS medical
program benefit. A decision notice may be a:
(a) “Basic decision
notice” mailed no later than the date of action given in the notice;
(b) “Combined Decision
notice” informs an individual or multiple family members of a household, when
feasible, of the eligibility decision made for each of the MAGI insurance affordability
programs;
(c) “Timely continuing
benefit decision notice” informs the client of the right to continued benefits
and is mailed no later than ten calendar days prior to the effective date of the
change, except for clients in the Address Confidentiality Program, for whom it should
be mailed no later than 15 calendar days prior to the effective date of the change.
(32) “Department”
means the Department of Human Services.
(33) “Dependent child”
means a child who is under the age of 18 or age 18 and a full-time student in a
secondary school or equivalent vocational or technical training, if before attaining
age 19 the child may reasonably be expected to complete the school or training.
(34) “ELA” (Express
Lane Agency) means the Department of Human Services making determinations regarding
one or more eligibility requirements for the MAGI Child or MAGI CHIP programs.
(35) “ELE” (Express
Lane Eligibility) means the Oregon Health Authority’s option to rely on a
determination made within a reasonable period by an ELA finding that a child satisfies
the requirements for MAGI Child or MAGI CHIP program eligibility.
(36) “Electronic account”
means an electronic file that includes all information collected and generated by
the Agency regarding each individual’s Medicaid or CHIP eligibility and enrollment,
including all required documentation and including any information collected or
generated as part of a fair hearing process conducted by the Authority, Cover Oregon,
or the FFM appeals process.
(37) “Electronic application”
means an application electronically signed and submitted through the Internet.
(38) “Eligibility determination”
means an approval or denial of eligibility and a renewal or termination of eligibility.
(39) “Expedited appeal”
also called “expedited hearing” means a hearing held within five working
days of the Authority’s receipt of a hearing request, unless the claimant
requests more time.
(40) “Family size”
means the number of individuals used to compare to the income standards chart for
the applicable program. The family size consists of all members of the Household
group and each unborn child of any pregnant members of the Household group.
(41) “Federal data
services hub” means an electronic service established by the Secretary of
the Department of Health and Human Services through which all insurance affordability
programs can access specified data from pertinent federal agencies needed to verify
eligibility, including SSA, the Department of Treasury, and the Department of Homeland
Security.
(42) “Federal poverty
level (FPL)” means the federal poverty level updated periodically in the Federal
Register by the Secretary of the Department of Health and Human Services under the
authority of 42 U.S.C. 9902(2) as in effect for the applicable budget period used
to determine an individual’s eligibility in accordance with 42 CFR 435.603(h).
(43) “Federally Facilitated
Marketplace” also called “FFM” means a website used by consumers.
(44) “Hearing Request”
means a clear expression, oral or written, by an individual or the individual’s
representative that the individual wishes to appeal an Authority or FFM decision
or action.
(45) “Household group”
consists of every individual whose income is considered for determining each medical
applicant’s eligibility as defined in OAR 410-200-0305.
(46) “Inmate”
means:
(a) An individual living
in a public institution that is:
(A) Confined involuntarily
in a local, state, or federal prison, jail, detention facility, or other penal facility,
including being held involuntarily in a detention center awaiting trial or serving
a sentence for a criminal offense;
(B) Residing involuntarily
in a facility under a contract between the facility and a public institution where,
under the terms of the contract, the facility is a public institution;
(C) Residing involuntarily
in a facility that is under governmental control; or
(D) Receiving care as an
outpatient while residing involuntarily in a public institution;
(b) An individual is not
considered an inmate when:
(A) The individual is released
on parole, probation, or post-prison supervision;
(B) The individual is on
home or work-release, unless the individual is required to report to a public institution
for an overnight stay;
(C) The individual is receiving
inpatient care at a medical institution not associated with the public institution
where the individual is an inmate;
(D) The individual is staying
voluntarily in a detention center, jail, or county penal facility after his or her
case has been adjudicated and while other living arrangements are being made for
the individual; or
(E) The individual is in
a public institution pending other arrangements as defined in 42 CFR 435.1010.
(47) “Insurance affordability
program” means a program that is one of the following:
(a) Medicaid;
(b) CHIP;
(c) A program that makes
coverage available in a qualified health plan through Cover Oregon or the FFM with
advance payments of the premium tax credit established under section 36B of the
Internal Revenue Code available to qualified individuals;
(d) A program that makes
coverage available in a qualified health plan through Cover Oregon or the FFM with
cost-sharing reductions established under section 1402 of the Affordable Care Act.
(48) “Lawfully present”
means an individual:
(a) Is a qualified non-citizen,
as defined in this section;
(b) Has valid non-immigrant
status, as defined in 8 U.S.C. 1101(a) (15) or otherwise under the immigration laws
(as defined in 8 U.S.C. 1101(a) (17));
(c) Is paroled into the United
States in accordance with 8 U.S.C. 1182(d)(5) for less than one year, except for
an individual paroled for prosecution, for deferred inspection or pending removal
proceedings; or
(d) Belongs to one of the
following classes:
(A) Granted temporary resident
status in accordance with 8 U.S.C. 1160 or 1255a, respectively;
(B) Granted Temporary Protected
Status (TPS) in accordance with 8 U.S.C. 1254a and individuals with pending applications
for TPS who have been granted employment authorization;
(C) Granted employment authorization
under 8 CFR 274a.12(c);
(D) Family Unity beneficiaries
in accordance with section 301 of Public Law 101–649, as amended;
(E) Under Deferred Enforced
Departure (DED) in accordance with a decision made by the President;
(F) Granted Deferred Action
status;
(G) Granted an administrative
stay of removal under 8 CFR part 241; (viii) Beneficiary of approved visa petition
that has a pending application for adjustment of status;
(e) Is an individual with
a pending application for asylum under 8 U.S.C. 158, or for withholding of removal
under 8 U.S.C. 1231, or under the Convention Against Torture who:
(A) Has been granted employment
authorization; or
(B) Is under the age of 14
and has had an application pending for at least 180 days;
(f) Has been granted withholding
of removal under the Convention Against Torture;
(g) Is a child who has a
pending application for Special Immigrant Juvenile status as described in 8 U.S.C.
1101(a) (27) (J);
(h) Is lawfully present in
American Samoa under the immigration laws of American Samoa;
(i) Is a victim of a severe
form of trafficking in persons, in accordance with the Victims of Trafficking and
Violence Protection Act of 2000, Public Law 106–386, as amended (22 U.S.C.
7105(b)); or
(j) Exception: An individual
with deferred action under the Department of Homeland Security’s deferred
action for childhood arrivals process, as described in the Secretary of Homeland
Security’s June 15, 2012 memorandum, may not be considered to be lawfully
present with respect to any of the above categories in sections (a) through (i)
of this rule.
(49) “Legal Argument”
has the meaning given that term in OAR 137-003-0008(c).
(50) “Medicaid”
means Oregon’s Medicaid program under Title XIX of the Social Security Act.
(51) “MAGI” means
Modified Adjusted Gross Income and has the meaning provided at IRC 36B(d)(2)(B)
and generally means federally taxable income with the following exceptions:
(a) The income of the following
individuals is excluded when they are not expected to be required to file a tax
return for the tax year in which eligibility is being determined. This subsection
applies whether or not the child or tax dependent actually files a tax return:
(A) Children, regardless
of age, who are included in the household of a parent;
(B) Tax dependents;
(b) In applying subsection
(a) of this section, IRC § 6012(a) (1) is used to determine who is required
to file a tax return.
(52) “MAGI-based income”
means income calculated using the same financial methodologies used to determine
MAGI as defined in section 36B(d)(2)(B) of the Code with the following exceptions:
(a) American Indian and Alaska
Native income exceptions;
(b) Child support;
(c) Life insurance proceeds;
(d) Non-taxable Veterans’
benefits;
(e) Non-taxable workers’
compensation benefits;
(f) Scholarships, awards,
or fellowship grants used for educational expenses;
(g) Supplemental Security
Income (SSI);
(h) An amount received as
a lump sum is counted as income only in the month received. Lump sum income includes
but is not limited to:
(A) Winnings;
(B) Countable educational
income;
(C) Capital gains;
(D) Dividends, interest,
royalties;
(i) Scholarships, awards,
or fellowship grants used for education purposes and not for living expenses;
(j) Self-employment and business
entity income is determined by adding gross receipts and other business income and
subtracting deductions described in Internal Revenue Code (IRC) §§ 161
through 249. Items not deductible are described in IRC §§ 261 through
280 include, but are not limited to, most capital expenditures, such as business
start-up costs, buildings, and furniture and payments or deductions for personal,
living, or family use. Business structures are determined by state statutes and
are dependent on elections made by business owners. Each state may use different
regulations for business structures. Salaries and wages paid to employees, including
those who are owners or stockholders, are countable income to the employees. Business
income is countable to owners and stockholders as described below:
(A) Sole proprietors, independent
contractors, and Limited Liability Companies (LLC) who choose to file federal taxes
as a sole proprietor: The necessary and ordinary costs of producing income are subtracted
from gross receipts and other business income to determine countable income. Expenses
related to costs for both business and personal use are prorated according to the
proportions used for each purpose. Costs are limited to those described in IRC §§161
through 199 and Treasury Regulations §§ Sec. 1.162 through 1.263;
(B) Partnerships that are
not publicly traded and LLCs who choose to file federal taxes as a partnership:
Owners’ income is determined as follows:
(i) The distributive share
of income, gain, and loss is determined proportionately according to the partnership
agreement or the LLC agreement;
(ii) Income from other partnerships,
estates, and trusts is added to the amount in paragraph (A) of this subsection;
(iii) The costs of producing
income described in subsection (4) (a) except for oil and gas depletion and costs
listed below are proportionately subtracted from gross receipts to determine each
partner’s countable income:
(I) Bad debts;
(II) Guaranteed payments
to partners;
(III) Losses from other partnerships,
farms, estates, and trusts;
(IV) Retirement plans;
(C) S Corporations and LLCs
who choose to file federal taxes as an S Corporation: Shareholders’ income
is determined as follows:
(i) The distributive share
of profits, gain, and loss are determined proportionately on the basis of the stockholders’
shares of stock;
(ii) The costs of producing
income described in subsection (a) are proportionately subtracted from gross receipts
to determine each stockholder’s countable income;
(iii) The distributive share
of profits is countable income to the shareholders whether or not it is actually
distributed to the shareholders;
(D) C Corporations and LLCs
who choose to file taxes as C Corporations: Shareholders’ income is countable
when it is distributed to them through dividends.
(53) “MAGI income standard”
means the monthly income standard for the relevant program and family size described
in OAR 410-200-0315.
(54) “Minimum essential
coverage” means medical coverage under:
(a) A government-sponsored
plan, including Medicare Part A, Medicaid (excluding CAWEM), CHIP, TRICARE, the
veterans’ health care program, and the Peace Corps program;
(b) Employer-sponsored plans
with respect to an employee, including coverage offered by an employer that is a
government plan, any other plan or coverage offered in the small or large group
market within the state, and any plan established by an Indian tribal government;
(c) Plans in the individual
market;
(d) Grandfathered health
plans; and
(e) Any other health benefits
coverage, such as a state health benefits risk pool, as recognized by the HHS secretary
in coordination with the Treasury Secretary.
(55) “Non-applicant”
means an individual not seeking an eligibility determination for him or herself
and is included in an applicant’s or beneficiary’s household to determine
eligibility for the applicant or beneficiary.
(56) “Non-citizen”
has the meaning given the term “alien” as defined in section 101(a)(3)
of the Immigration and Nationality Act (INA), (8 U.S.C. 1101(a)(3)) and includes
any individual who is not a citizen or national of the United States, defined at
8 U.S.C. 1101(a)(22).
(57) “OCCS” means
the Office of Client and Community Services, part of the Division of Medical Assistance
Programs under the Oregon Health Authority.
(58) “OCCS medical
programs” means all programs under the Office of Client and Community Services
including:
(a) “CEC” means
Continuous Eligibility for OHP-CHP pregnant women. Title XXI medical assistance
for a pregnant non-CAWEM child found eligible for the OHP-CHP program who, for a
reason other than moving out of state or becoming a recipient of private major medical
health insurance, otherwise would lose her eligibility;
(b) “CEM” means
Continuous Eligibility for Medicaid: Title XIX medical assistance for a non-CAWEM
child found eligible for Medicaid who loses his or her eligibility for a reason
other than turning 19 years of age or moving out of state;
(c) “EXT” means
Extended Medical Assistance. The Extended Medical Assistance program provides medical
assistance for a period of time after a family loses its eligibility for the MAA,
MAF, or PCR program due to an increase in their spousal support or earned income;
(d) “MAA” means
Medical Assistance Assumed;
(e) “MAF” means
Medical Assistance to Families. The Medical Assistance to Families program provides
medical assistance to people who are ineligible for MAA but are eligible for Medicaid
using ADC program standards and methodologies that were in effect as of July 16,
1996;
(f) “OHP” means
Oregon Health Plan. The Oregon Health Plan program provides medical assistance to
many low-income individuals and families. The program includes five categories of
individuals who may qualify for benefits. The acronyms for these categories are:
(A) “OHP-CHP”
Persons under 19. OHP coverage for persons under 19 years of age who qualify at
or below the 300 percent income standard;
(B) “OHP-OPC”
Children. OHP coverage for children who qualify under the 100 percent income standard;
(C) “OHP-OPP”
Pregnant Females and their newborn children. OHP coverage for pregnant females who
qualify under the 185 percent income standard and their newborn children;
(D) “OHP-OPU”
Adults. OHP coverage for adults who qualify under the 100 percent income standard.
A person eligible under OHP-OPU is referred to as a health plan new/non-categorical
(HPN) client;
(E) “OHP-OP6”
Children under 6. OHP coverage for children under age 6 who qualify under the 133
percent income standard;
(g) “Substitute Care”
means medical coverage for children in BRS or PRTF;
(h) “BCCTP” means
Breast and Cervical Cancer Treatment Program;
(i) “MAGI Medicaid/CHIP”
means OCCS medical programs for which eligibility is based on MAGI, including:
(A) MAGI Child;
(B) MAGI Parent or Other
Caretaker Relative;
(C) MAGI Pregnant Woman;
(D) MAGI Children’s
Health Insurance Program (CHIP);
(E) MAGI Adult.
(59) “OCWP” means
Office of Child Welfare Programs.
(60) “OSIPM”
means Oregon Supplemental Income Program Medical. Medical coverage for elderly and
disabled individuals administered by the Department of Human Services, Aging and
People with Disabilities and Developmental Disabilities.
(61) “Parent”
means a natural or biological, adopted, or step parent.
(62) “Personal Injury”
means a physical or emotional injury to an individual including, but not limited
to, assault, battery, or medical malpractice arising from the physical or emotional
injury.
(63) “Post-eligibility
review” means a review period of 30 days following the eligibility determination
during which the Authority will verify information used to approve OCCS medical
program benefits and ensure all non-financial eligibility requirements are met (OAR
410-200-0230).
(64) “Pregnant woman”
means a woman during pregnancy and the postpartum period that begins on the date
the pregnancy ends, extends 60 days and ends on the last day of the month in which
the 60-day period ends.
(65) “Primary contact”
means the primary person the Agency will communicate with and:
(a) Is listed as the case
name; or
(b) Is the individual named
as the primary contact on the Cover Oregon, Authority, or FFM medical application.
(66) “Private major
medical health insurance” means a comprehensive major medical insurance plan
that at a minimum provides physician services, inpatient and outpatient hospitalization,
outpatient lab, x-ray, immunizations, and prescription drug coverage. This term
does not include coverage under the Kaiser Child Health Program or Kaiser Transition
Program but does include policies that are purchased privately or are employer-sponsored.
(67) “PRTF” means
Psychiatric Residential Treatment Facility.
(68) “Public institution”
means any of the following:
(a) A state hospital (ORS
162.135);
(b) A local correctional
facility (ORS 169.005), a jail, or prison for the reception and confinement of prisoners
that is provided, maintained, and operated by a county or city and holds individuals
for more than 36 hours;
(c) A Department of Corrections
institution (ORS 421.005), a facility used for the incarceration of individuals
sentenced to the custody of the Department of Corrections, including a satellite,
camp, or branch of a facility;
(d) A youth correction facility
(ORS 162.135):
(A) A facility used for the
confinement of youth offenders and other individuals placed in the legal or physical
custody of the youth authority, including a secure regional youth facility, a regional
accountability camp, a residential academy and satellite, and camps and branches
of those facilities; or
(B) A facility established
under ORS 419A.010 to 419A.020 and 419A.050 to 419A.063 for the detention of children,
wards, youth or youth offenders pursuant to a judicial commitment or order;
(e) As used in this rule,
the term public institution does not include:
(A) A medical institution
as defined in 42 CFR 435.1010 including the Secure Adolescent Inpatient Program
(SAIP) and the Secure Children's Inpatient Program (SCIP);
(B) An intermediate care
facility as defined in 42 CFR 440.140 and 440.150; or
(C) A publicly operated community
residence that serves no more than 16 residents, as defined in 42 CFR 435.1009.
(69) “Qualified Hospital”
means a hospital that:
(a) Participates as an enrolled
Oregon Medicaid provider;
(b) Notifies the Authority
of their decision to make presumptive eligibility determinations;
(c) Agrees to make determinations
consistent with Authority policies and procedures;
(d) Informs applicants for
presumptive eligibility of their responsibility and available assistance to complete
and submit the full Medicaid application and to understand any documentation requirements;
and
(e) Are not disqualified
by the Authority for violations related to standards established for the presumptive
eligibility program under 42 CFR § 435.1110(d).
(70) “Qualified non-citizen”
means an individual that is any of the following:
(a) A non-citizen lawfully
admitted for permanent residence under the INA (8 U.S.C. 1101 et seq);
(b) A refugee admitted to
the United States as a refugee under section 207 of the INA (8 U.S.C. 1157);
(c) A non-citizen granted
asylum under section 208 of the INA (8 U.S.C. 1158);
(d) A non-citizen whose deportation
is being withheld under section 243(h) of the INA (8 U.S.C. 1253(h)) (as in effect
immediately before April 1, 1997) or section 241(b) (3) of the INA (8 U.S.C. 1231(b)
(3)) (as amended by section 305(a) of division C of the Omnibus Consolidated Appropriations
Act of 1997, Pub. L. No. 104-208, 110 Stat. 3009-597 (1996));
(e) A non-citizen paroled
into the United States under section 212(d) (5) of the INA (8 U.S.C. 1182(d) (5))
for a period of at least one year;
(f) A non-citizen granted
conditional entry pursuant to section 203(a) (7) of the INA (8 U.S.C. 1153(a) (7))
as in effect prior to April 1, 1980;
(g) A non-citizen who is
a Cuban and Haitian entrant (as defined in section 501(3) of the Refugee Education
Assistance Act of 1980);
(h) An Afghan or Iraqi alien
granted Special Immigration Status (SIV) under section 101(a) (27) of the INA; or
(i) A battered spouse or
dependent child who meets the requirements of 8 U.S.C. 1641(c) and is in the United
States on a conditional resident status, as determined by the U.S. Citizenship and
Immigration Services.
(71) “Reasonable opportunity
period:”
(a) May be used to obtain
necessary verification or resolve discrepancy regarding US citizenship or non-citizen
status;
(b) Begins on and shall extend
90 days from the date on which notice is received by the individual. The date on
which the notice is received is considered to be five days after the date on the
notice, unless the individual shows that he or she did not receive the notice within
the five-day period;
(c) May be extended beyond
90 days if the individual is making a good faith effort to resolve any inconsistencies
or obtain any necessary documentation or the Agency needs more time to complete
the verification process.
(72) “Redetermination”
means a review of eligibility outside of regularly scheduled renewals. Redeterminations
that result in the assignment of a new renewal date are considered renewals.
(73) “Renewal”
means a regularly scheduled periodic review of eligibility resulting in a renewal
or change of program benefits, including the assignment of a new renewal date or
a change in eligibility status.
(74) “Required documentation”
means:
(a) Facts to support the
Agency's decision on the application; and
(b) Either:
(A) A finding of eligibility
or ineligibility; or
(B) An entry in the case
record that the applicant voluntarily withdrew the application, and the Agency sent
a notice confirming the decision, that the applicant has died, or that the applicant
cannot be located.
(75) “Secure electronic
interface” means an interface which allows for the exchange of data between
Medicaid or CHIP and other insurance affordability programs and adheres to the requirements
in 42 CFR part 433, subpart C.
(76) “Shared eligibility
service” means a common or shared eligibility system or service used by a
state to determine individuals’ eligibility for insurance affordability programs.
(77) “Sibling”
means natural or biological, adopted, or half or step sibling.
(78) “Spouse”
means an individual who is legally married to another individual under:
(a) The statutes of the state
where the marriage occurred;
(b) The common law of the
state in which two individuals previously resided while meeting the requirements
for common law marriage in that state; or
(c) The laws of a country
in which two individuals previously resided while meeting the requirements for legal
marriage in that country.
(79) “SSA” means
Social Security Administration.
(80) “Tax dependent“
has meaning given the term “dependent” under section 152 of the Internal
Revenue Code, as an individual for whom another individual claims a deduction for
a personal exemption under section 151 of the Internal Revenue Code for a taxable
year.
(81) “Title IV-E”
means Title IV-E of the Social Security Act (42 U.S.C. §§ 671-679b).
Stat. Auth.: ORS 411.095, 411.402, 411.404,
413.038, 414.025, 414.534
Stats. Implemented: ORS 411.095,
411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025,
414.231, 411.447, 414.534, 414.536, 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0100
Coordinated Eligibility and Enrollment
Process with the Department of Human Services and Cover Oregon
(1) This rule describes Oregon Health
Authority’s (Authority) coordination of eligibility and enrollment with the
Department of Human Services (Department), Cover Oregon, and the FFM. The Authority
shall:
(a) Minimize the burden on
individuals seeking to obtain or renew eligibility or to appeal a determination
of eligibility for insurance affordability programs;
(b) Ensure determinations
of eligibility and enrollment in the appropriate program without undue delay, consistent
with timeliness standards described in OAR 410-200-0110 based on the application
date;
(c) Provide coordinated content
for those household members whose eligibility status is not yet determined; and
(d) Screen every applicant
or beneficiary who submits an application or renewal form, or whose eligibility
is being renewed under a change in circumstance for criteria that identify individuals
for whom MAGI-based income methods do not apply.
(2) For individuals undergoing
eligibility determination based on MAGI-based methodology and standards, the Authority,
consistent with the timeliness standards described in OAR 410-200-0110, shall:
(a) Determine eligibility
for MAGI Medicaid/CHIP on the basis of having household income at or below the applicable
MAGI-based standard, or
(b) If ineligible under section
(a) or if eligible for CAWEM-level benefits only, direct as appropriate to Cover
Oregon for the 2014 benefit year or the FFM for the 2015 benefit year.
(3) If ineligible for MAGI
Medicaid/CHIP, the Authority shall, consistent with the timeliness standards described
in OAR 410-200-0110:
(a) Screen for eligibility
for non-MAGI programs as indicated by information provided on the application or
renewal form;
(b) Transfer timely via secure
electronic interface the individual’s electronic account information to the
Department, as appropriate, OCCS medical program;
(c) Provide notice to the
individual that:
(A) The Authority has determined
the individual ineligible for OCCS medical programs;
(B) The Department is continuing
to evaluate Medicaid eligibility on one or more other bases, including a plain language
explanation of the other bases being considered;
(C) The notice shall include
coordinated content relating to the transfer of the individual’s electronic
account to the Department, as appropriate; and
(D) There is a right to a
hearing to challenge the eligibility decision;
(d) Provide or assure that
the Department has provided the individual with notice of the final determination
of eligibility on one or more other bases.
(4) For beneficiaries found
ineligible for on-going OCCS medical program benefits who are referred to the Department
for a non-MAGI Medicaid eligibility review, the Authority shall maintain OCCS medical
program benefits while eligibility is being determined by the Department and may
not take action to close benefits until determination of eligibility is complete.
(5) Coordination among agencies:
(a) The Authority shall maintain
a secure electronic interface through which the Authority can receive an individual’s
electronic account from the Department, Cover Oregon, and the FFM;
(b) The Authority may not
request information or documentation from the individual included in the individual’s
electronic account or provided to the Agency; and
(c) If information is available
through electronic data match and is useful and related to eligibility for OCCS
medical programs, the Authority shall obtain the information through electronic
data match.
(6) Cover Oregon may perform
any obligation of the Authority under these rules pertaining to MAGI Medicaid/CHIP
except for hospital presumptive eligibility. Each Agency shall either complete the
processing of any application or redetermination for medical benefits or transfer
the application to another Agency for completion.
Stat. Auth.: ORS 411.402, 411.404, 413.042
& 414.534
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231,
411.447, 414.534, 414.536 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0105
Hospital Presumptive Eligibility
This rule sets out when an individual
is presumptively eligible for MAGI Medicaid/CHIP, BCCTP, and Former Foster Care
Youth Medical (OAR 413-100-0457) based on the determination of a qualified hospital.
(1) The qualified hospital
will determine Hospital Presumptive Eligibility for MAGI Medicaid/CHIP, BCCTP, or
Former Foster Care Youth Medical based on the following information attested by
the individual:
(a) Family size;
(b) Household income;
(c) Receipt of other health
coverage;
(d) US citizenship, US national,
or non-citizen status.
(2) To be eligible via Hospital
Presumptive Eligibility, an individual must be a US citizen, US National, or meet
the citizenship and alien status requirements found in 410-200-0215 and one of the
following:
(a) A child under the age
of 19 with income at or below 300 percent of the federal poverty level;
(b) A parent or caretaker
relative of a dependent child with income at or below the MAGI Parent or Other Caretaker
Relative income standard for the appropriate family size in OAR 410-200-0315;
(c) A pregnant woman with
income at or below 185 percent of the federal poverty level;
(d) A non-pregnant adult
between the ages of 19 through 64 with income at or below 133 percent of the federal
poverty level; or
(e) A woman under the age
of 65 who has been determined eligible for the Breast and Cervical Cancer Treatment
Program (OAR 410-200-0400);
(f) An individual under the
age of 26 who was in Oregon foster care on their 18th birthday.
(3) To be eligible via Hospital
Presumptive Eligibility, an individual may not:
(a) Be receiving Supplemental
Security Income benefits;
(b) Be a Medicaid/CHIP beneficiary;
or
(c) Have received Hospital
Presumptive Eligibility for any portion of the full year (365 days) preceding a
new Hospital Presumptive Eligibility period.
(4) In addition to the requirements
outlined in sections (2) and (3) above, the following requirements also apply:
(a) To receive MAGI Adult
benefits via Hospital Presumptive Eligibility, an individual may not be entitled
to or enrolled in Medicare benefits under part A or B of Title XVIII of the Act;
(b) To receive MAGI CHIP
benefits via Hospital Presumptive Eligibility, an individual may not be covered
by any minimum essential coverage that is accessible (OAR 410-200-0410(2)(c));
(c) To receive BCCTP benefits
via Hospital Presumptive Eligibility, an individual may not be covered by any minimum
essential coverage.
(5) The Hospital Presumptive
Eligibility period begins on the earlier of:
(a) The date the qualified
hospital determines the individual is eligible; or
(b) The date that the individual
received a covered medical service from the qualified hospital, if the hospital
determines the individual is eligible and submits the decision to the Authority
within five calendar days following the date of service.
(6) The Hospital Presumptive
Eligibility period ends:
(a) For individuals on whose
behalf a Medicaid/CHIP application has been filed by the last day of the month following
the month in which the hospital presumptive eligibility period begins, the day on
which the state makes an eligibility determination for MAGI Medicaid/CHIP and sends
basic decision notice; or
(b) If subsection (a) is
not completed, the last day of the month following the month in which the hospital
presumptive eligibility period begins.
(7) A Hospital Presumptive
Eligibility decision does not qualify a beneficiary for continuous eligibility (OAR
410-200-0135).
(8) A baby born to a woman
receiving benefits during a Hospital Presumptive Eligibility period is not assumed
eligible (OAR 410-200-0135).
Stat. Auth.: ORS 411.402, 411.404, 413.042
& 414.534
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231,
411.447, 414.534, 414.536 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0110
Application and Renewal Processing and
Timeliness Standards
(1) General information as it relates
to application processing is as follows:
(a) An individual may apply
for one or more medical programs administered by the Authority, the Department,
or Cover Oregon using a single streamlined application;
(b) An application may be
submitted via the Internet, the FFM, by telephone, by mail, in person, or through
other commonly available electronic means;
(c) The Agency shall ensure
that an application form is readily available to anyone requesting one and that
community partners or Agency staff are available to assist applicants to complete
the application process;
(d) If the Agency requires
additional information to determine eligibility, the Agency shall send the applicant
or beneficiary written notice that includes a statement of the specific information
needed to determine eligibility and the date by which the applicant or beneficiary
shall provide the required information in accordance with section (7) of this rule.
(e) If an application is
filed containing the applicant or beneficiary’s name and address, the Agency
shall send the applicant or beneficiary a decision notice within the time frame
established in section (7) of this rule;
(f) An application is complete
if all of the following requirements are met:
(A) All information necessary
to determine the individual’s eligibility and benefit level is provided on
the application for each individual in the household group;
(B) The applicant, even if
homeless, provides an address where they can receive postal mail;
(C) The application is signed
in accordance with section (6) of this rule;
(D) The application is received
by the Agency;
(g) To complete the application
process, the applicant shall:
(A) With the exception of
sections (5) and (6) of this rule, complete and sign an application; and
(B) Provide necessary information
to the Agency within the time frame established in section (7) of this rule.
(2) General information as
it relates to renewal and redetermination processing is as follows:
(a) The Authority shall redetermine
eligibility at assigned intervals and whenever a beneficiary’s eligibility
becomes questionable;
(b) When renewing or redetermining
medical benefits, the Agency shall, to the extent feasible, determine eligibility
using information found in the beneficiary’s electronic account and electronic
data accessible to the Agency;
(c) If the Agency is unable
to determine a beneficiary’s eligibility using information found in the beneficiary’s
electronic account and electronic data accessible to the Agency, then the Agency
shall provide a pre-populated renewal form to the beneficiary containing information
known to the Agency, a statement of the additional information needed to renew eligibility,
and the date by which the beneficiary must provide the required information in accordance
with section (7) of this rule;
(d) The Agency shall assist
applicants seeking assistance to complete the pre-populated renewal form or gather
information necessary to renew eligibility;
(e) The pre-populated renewal
form is complete if it meets the requirements identified in section (1) (e) of this
rule;
(f) If the Agency provides
the individual with a pre-populated renewal form to complete the renewal process,
the individual must:
(A) Complete and sign the
form in accordance with section (6) of this rule;
(B) Submit the form via the
Internet, by telephone, via mail, in person, and through other commonly available
electronic means, and
(C) Provide necessary information
to the Agency within the time frame established in section (7) of this rule;
(g) An individual may withdraw
their pre-populated renewal form at any time.
(3) Except for individuals
found eligible for MAGI Medicaid/CHIP through the Fast-Track enrollment process
(OAR 410-200-0505), for renewals due between July 1, 2014 and December 31, 2014,
the Authority will:
(a) Utilize a pre-populated
Expedited Renewal form to determine if the individual has experienced:
(A) A change in household
members; or
(B) A change in income;
(b) Renew eligibility based
on the individual’s attested information on the Expedited Renewal form if:
(A) There is no change in
household members; and
(B) The attested income allows
all beneficiaries to remain eligible for Medicaid/CHIP;
(c) If unable to renew eligibility
based on the individual’s attested information on the Expedited Renewal form,
the Authority will send the beneficiary an application in order to complete a full
eligibility review.
(4) A new application is
required when:
(a) An individual requests
medical benefits and no member of the household group currently receives OCCS medical
program benefits;
(b) A child turns age 19,
is no longer claimed as a tax dependent, and wishes to retain medical benefits;
(c) The Authority determines
that an application is necessary to complete an eligibility determination.
(5) A new application is
not required when:
(a) The Agency determines
an applicant is ineligible in the month of application and:
(A) Is determining if the
applicant is eligible the following month; or
(B) Is determining if the
applicant is eligible retroactively (OAR 410-200-0130);
(b) Determining initial eligibility
for OCCS medical programs via Fast-Track enrollment pursuant to OAR 410-200-0505;
(c) Benefits are closed and
reopened during the same calendar month;
(d) An individual’s
medical benefits were suspended because they became an inmate and met the requirements
of OAR 410-200-0140;
(e) An assumed eligible newborn
(AEN) is added to a household group receiving medical program benefits;
(f) An individual not receiving
medical program benefits is added to an on-going household group receiving medical
program benefits, and eligibility can be determined using information found in the
individual or beneficiary’s electronic account and electronic data available
to the Agency;
(g) Redetermining or renewing
eligibility for beneficiaries and the Agency has sufficient evidence to redetermine
or renew eligibility for the same or new program;
(h) At renewal, the beneficiary
fails to submit additional information requested by the Agency within 30 days but
provides the requested information within 90 days after the date medical benefits
were terminated.
(6) Signature requirements
are as follows:
(a) The application must
be signed by one of the following:
(A) The primary contact;
(B) At least one caretaker
relative or parent in the household group;
(C) The primary contact when
there is no parent in the household group; or
(D) An authorized representative;
(b) Hospital Presumptive
Eligibility may be determined without a signature described in section (a);
(c) When renewing eligibility,
if the Agency is unable to determine eligibility using information found in the
beneficiary’s electronic account and electronic data accessible to the Agency,
a signature is required on the pre-populated renewal form sent to the beneficiary
for additional information;
(d) Signatures may be submitted
and shall be accepted by the Agency via Internet, mail, telephone, in person, or
other electronic means;
(e) An electronic application
must be submitted to and received by the Authority with an electronic signature.
(7) Application and renewal
processing timeliness standards are as follows:
(a) At initial eligibility
determination, the Agency shall inform the individual of timeliness standards, make
an eligibility determination, and send a decision notice not later than the 45th
calendar day after the Date of Request if:
(A) All information necessary
to determine eligibility is present; or
(B) The application is not
completed by the applicant within 45 days after the Date of Request;
(b) At initial eligibility
determination, the Agency may extend the 45-day period described in section (a)
if there is an administrative or other emergency beyond the control of the Agency.
The Agency must document the emergency;
(c) Except for periodic renewals
of eligibility described in section (d), the Agency provides:
(A) The reasonable opportunity
period to obtain necessary verification or resolve discrepancy regarding US citizenship
or non-citizen status after eligibility has been determined; or
(B) The post-eligibility
review period to verify information used to approve OCCS medical program benefits
and ensure all non-financial eligibility requirements are met;
(d) At periodic renewal of
eligibility, if additional information beyond data available to the Agency on the
beneficiary’s electronic account or electronic data is required, the Authority
shall provide the beneficiary at least 30 days from the date of the renewal form
to respond and provide necessary information.
(8) Individuals may apply
through the FFM. The FFM will determine eligibility for OCCS Medicaid/CHIP. Oregon
will accept determinations made by the FFM and sent to the Authority. The Authority
will enroll eligible individuals as indicated by the FFM.
(9) Medical program eligibility
is determined in the following order:
(a) For a child applicant,
the order is as follows:
(A) Assumed eligibility for
OCCS medical programs (OAR 410-200-0135);
(B) Substitute Care, when
the child is in Behavioral Rehabilitation Services (BRS) or in Psychiatric Residential
Treatment Facility (PRTF) (OAR 410-200-0405);
(C) MAGI Parent or Other
Caretaker Relative (OAR 410-200-0420);
(D) MAGI Pregnant Woman program
(OAR 410-200-0425);
(E) MAGI Child (OAR 410-200-0415);
(F) Continuous Eligibility
(OAR 410-200-0135);
(G) MAGI CHIP (OAR 410-200-0410);
(H) EXT (OAR 410-200-0440);
(b) For an adult applicant,
the order is as follows:
(A) Assumed eligibility for
OCCS medical programs (OAR 410-200-0135);
(B) Substitute Care (OAR
410-200-0405);
(C) MAGI Parent or Other
Caretaker Relative (OAR 410-200-0420);
(D) EXT (OAR 410-200-0440);
(E) MAGI Pregnant Woman (OAR
410-200-0425);
(F) MAGI Adult (OAR 410-200-0435);
(G) BCCTP (OAR 410-200-0400).
Stat. Auth.: ORS 411.402, 411.404, 413.042
& 414.534
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231,
411.447, 414.534, 414.536 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0111
Authorized Representatives
(1) The following individuals may designate
an authorized representative:
(a) A caretaker;
(b) The primary contact when
there is no caretaker in the household group;
(c) An adult in the household
group; or
(d) The Agency, if an authorized
representative is needed but has not been designated by the individual.
(2) The Agency shall accept
an applicant or beneficiary’s designation of an authorized representative
via any of the following methods which must include either a handwritten or electronic
signature of both the applicant or beneficiary and designated authorized representative:
(a) The Internet;
(b) E-mail;
(c) Mail;
(d) Telephonic recording;
(e) In person; or
(f) Other electronic means.
(3) Applicants and beneficiaries
may authorize their authorized representative to:
(a) Sign an application on
the applicant’s behalf;
(b) Complete and submit a
renewal form;
(c) Receive copies of the
applicant or beneficiary’s notices and other communications from the Agency;
or
(d) Act on behalf of the
applicant or beneficiary in any or all other matters with the Agency.
(4) The authorized representative
must:
(a) Fulfill all responsibilities
encompassed within the scope of the authorized representation as identified in section
(3) to the same extent as the individual represented; and
(b) Maintain the confidentiality
of any information regarding the applicant or beneficiary provided by the Authority.
(5) In addition to authorized
representatives as designated in sections (1) through (4) above, an individual is
treated as an authorized representative if the individual has been given authority
under state law. Such authority includes but is not limited to:
(a) A court order establishing
legal guardianship;
(b) A health care representative,
when the individual is unable to make their own decisions; or
(c) A court order establishing
power of attorney.
(6) As a condition of serving
as an authorized representative, a provider or staff member or volunteer of an organization
with a service-providing relationship to the beneficiary must affirm that he or
she will adhere to the regulations in 45 CFR 431, subpart F and at 45 CFR 155.260(f)
and at 45 CFR 447.10 as well as other relevant state and federal laws concerning
conflicts of interest and confidentiality of information.
(7) The power to act as an
authorized representative is valid until the Agency is notified via any of the methods
described in section (2) of any of the following:
(a) The applicant or beneficiary
modifies the authorization or notifies the Agency that the representative is no
longer authorized to act on his or her behalf;
(b) The authorized representative
informs the Agency that he or she no longer is acting in such capacity; or
(c) There is a change in
the legal authority upon which the individual or organization’s authority
was based.
Stat. Auth.: ORS 411.402, 411.404, 413.042
& 414.534
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231,
411.447, 414.534, 414.536 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0115
OCCS Medical Programs— Effective Dates
(1) Date of Request:
(a) For all OCCS medical
programs, the applicant or an individual authorized to act on behalf of the applicant
must contact the Authority, the Department, Cover Oregon, or the FFM to request
medical benefits. The request may be via the Internet, by telephone, community partner,
by mail, by electronic communication, or in person.
(b) The Date of Request is
the earlier of the following:
(A) The date the request
for medical benefits is received; or
(B) The date the applicant
received a medical service, if the request for medical benefits is received by midnight
of the following business day;
(c) For current beneficiaries
of OCCS medical programs, the Date of Request is one of the following:
(A) The date the beneficiary
reports a change requiring a redetermination of eligibility; or
(B) The date the Agency initiates
a review, except that the automatic mailing of an application does not constitute
a Date of Request;
(d) The Date of Request starts
the application processing time frame;
(e) If the application is
required under OAR 410-200-0110 and is not received within 45 days after the Date
of Request or within the extended time that the Authority has allowed under OAR
410-200-0110, the new Date of Request is the date the application is submitted to
the Agency.
(2) For EXT, the effective
date is determined according to OAR 410-200-0440.
(3) Except for EXT, the effective
date of medical benefits for new applicants for OCCS medical programs is whichever
comes first:
(a) The Date of Request,
if the applicant is found eligible as of that date; or
(b) If ineligible on the
Date of Request, the first day following the Date of Request on which the client
is determined to be eligible within the month of the Date of Request or the following
month.
(4) The effective date for
retroactive medical benefits (OAR 410-200-0130) for MAGI Medicaid/CHIP and BCCTP
is the earliest date of eligibility during the three months preceding the Date of
Request. The Authority reviews each month individually for retroactive medical eligibility.
(5) Establishing a renewal
date:
(a) Except for EXT and MAGI
Pregnant Woman, as provided in subsection (b) for all OCCS medical programs, eligibility
shall be renewed every 12 months. The renewal date is the last day of the month
determined as follows:
(A) For initial eligibility,
the renewal date is determined by counting 12 full months following the initial
month of eligibility;
(B) For renewals that are
regularly scheduled, the new renewal date is determined by counting 12 full months
following the current renewal month;
(C) For redeterminations
that are the result of a reported change, the new renewal date is determined by
counting 12 full months following the month the change occurred;
(b) Except for OHP-OPP and
individuals who are 18 turning 19 years of age, all OCCS medical program beneficiaries
who have renewal dates between October 1, 2013, and March 31, 2014, the renewal
date shall be extended as follows:
(A) Renewal dates that fall
in October 2013 shall be extended to July 2014;
(B) Renewal dates that fall
in November 2013 shall be extended to August 2014;
(C) Renewal dates that fall
in December 2013 shall be extended to September 2014;
(D) Renewal dates that fall
in January 2014 shall be extended to July 2014;
(E) Renewal dates that fall
in February 2014 shall be extended to August 2014;
(F) Renewal dates that fall
in March 2014 shall be extended to September 2014;
(G) Renewal dates that fall
in April 2014 shall be extended to October 2014;
(H) Renewal dates that fall
in May 2014 shall be extended to November 2014;
(I) Renewal dates that fall
in June 2014 shall be extended to December 2014.
(6) Acting on Reported Changes
(also see Changes That Must Be Reported OAR 410-200-0235):
(a) When the beneficiary
reports a change in circumstances at any time other than the renewal month, eligibility
shall be redetermined for all household group members;
(b) Except for OHP-OPP, MAGI
Pregnant Woman, and MAGI Parent or Other Caretaker Relative, based on the reported
change, if the beneficiary is determined to be eligible for another OCCS medical
program, the effective date for the change is the first of the month following the
month in which the determination was made;
(c) For OHP-OPP, MAGI Pregnant
Woman, and MAGI Parent or Other Caretaker Relative, the effective date is the Date
of Request;
(d) For OCCS medical program
beneficiaries who were found eligible for OCCS medical program benefits using non-MAGI-based
methods with a benefit start date of December 31, 2013 or earlier who report changes
that may affect eligibility, the following apply:
(A) Eligibility shall be
redetermined using the budgeting policies outlined in OARs 410-200-0310 and 410-200-0315;
and
(B) If ineligible for Medicaid/CHIP
benefits as a result of the redetermination, the effective date of the change shall
be delayed until April 1, 2014, the end of the month following timely notice or
the next scheduled renewal, whichever is later;
(C) OCCS medical program
benefits shall be maintained during the period of time between the loss of eligibility
and the APTC or closure effective date of April 1, 2014.
(7) Assumed eligibility:
(a) A pregnant woman eligible
for and receiving Medicaid benefits the day the pregnancy ends or who was eligible
for and receiving medical under any Medicaid program and becomes ineligible while
pregnant is assumed eligible for continuous eligibility through the end of the calendar
month in which the 60th day following the last day of the pregnancy falls unless:
(A) She is no longer an Oregon
resident; or
(B) She requests medical
benefits to be closed;
(b) A child born to a mother
eligible for and receiving Medicaid, OHP-CHP, or MAGI CHIP benefits is an assumed
eligible newborn (AEN) for medical benefits until the end of the month the child
turns one year of age, unless:
(A) The child dies;
(B) The child is no longer
an Oregon resident; or
(C) The child’s representative
requests a voluntary termination of the child’s eligibility.
(8) Twelve-Month Continuous
Eligibility:
(a) A child determined eligible
for MAGI Medicaid/CHIP or BCCTP at initial eligibility or at the renewal period
shall have a 12-month continuous enrollment period. The 12-month continuous enrollment
period begins on the Date of Request or date the child is initially found eligible,
whichever is later, and continues for the following 12 full months;
(b) For a child transitioning
from another Medicaid program, the 12-month continuous enrollment period begins
the first month following the month in which the other Medicaid program ends.
(9) Suspending or Closing
Medical Benefits:
(a) The effective date for
closing all OCCS medical program benefits is the earliest of:
(A) The date of a beneficiary’s
death;
(B) The last day of the month
in which the beneficiary becomes ineligible and a timely continuing benefit decision
notice is sent;
(C) The day prior to the
start date for Office of Child Welfare Programs or OSIPM for beneficiaries transitioning
from an OCCS medical program;
(D) The date the program
ends; or
(E) The last day of the month
in which a timely continuing benefit decision notice is sent if on-going eligibility
cannot be determined because the beneficiary does not provide required information
within 30 days;
(b) Prior to closing medical
benefits, the Agency shall determine eligibility for all other insurance affordability
programs;
(c) For suspension of OCCS
medical program eligibility of beneficiaries who become incarcerated (OAR 461-200-0140).
(10) Denial of Benefits.
The effective date for denying OCCS medical program benefits is the earlier of the
following:
(a) The date the decision
is made that the applicant is not eligible and notice is sent; or
(b) The end of the application
processing time frame, unless the time period has been extended to allow the applicant
more time to provide required verification.
(11) Eligibility Following
Closure:
(a) The Authority shall redetermine
in a timely manner (OAR 410-200-0110), without requiring a new application, the
eligibility of an individual who:
(A) Lost OCCS medical program
eligibility because they did not submit required information needed to renew eligibility;
and
(B) Within 90 days of the
medical closure date, submits the required information needed to renew eligibility.
(b) If the individual is
found to meet OCCS medical program eligibility based on the completed redetermination
using the original budget month, eligibility shall be restored effective the earliest
date following the medical closure date on which the individual requested benefits,
as long as all necessary information is submitted within 90 days following the medical
closure date.
(c) The date described in
section (b) establishes a new date of request (see section (1)) and budget month
(410-200-0310) if:
(A) The individual is ineligible
based on the completed redetermination using the original budget month; or
(B) All necessary information
is not submitted within 90 days following the medical closure date.
Stat. Auth.: ORS, 411.402, 411.404,
413.042 & 414.534
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231,
411.447, 414.534, 414.536 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0120
Notices
(1) Except as provided in this rule,
the Authority shall send:
(a) A basic decision notice
whenever an application for OCCS medical program benefits is approved or denied;
(b) A timely continuing benefit
decision notice whenever OCCS medical program benefits are reduced or closed.
(2) For a beneficiary who
is placed in a public institution or a correctional facility, the Authority shall
send a basic decision notice to close, reduce, or suspend OCCS medical program benefits.
(3) For a beneficiary who
has been placed in skilled nursing care, intermediate care, or long-term hospitalization,
the Authority shall send a basic decision notice to close, suspend, or reduce OCCS
medical program benefits.
(4) The Authority shall send
a basic decision notice to close OCCS medical program benefits for a beneficiary
who has received them for less than 30 days and who is ineligible for any insurance
affordability program.
(5) When returned mail is
received without a forwarding address and the beneficiary’s whereabouts are
unknown, the Authority shall send a basic decision notice to end benefits if the
mail was sent by postal mail. If the returned mail was sent electronically, the
Authority shall resend by postal mail within three business days. The date on the
notice shall be the date the notice is sent by postal mail.
(6) The Authority shall send
one of the following notices when a beneficiary ceases to be an Oregon Resident:
(a) A timely continuing benefit
notice; or
(b) A basic decision notice
if the beneficiary is eligible for benefits in the other state.
(7) Except as provided in
section (9) of this rule, to close medical program benefits based on a request made
by the beneficiary, another adult member of the household group or the authorized
representative, the Authority shall send the following decisions notices:
(a) A timely continuing benefit
decision notice when an oral request is made to close benefits;
(b) A basic decision notice
when a request to withdraw, end, or reduce benefits is made with written signature
or recorded verbal signature;
(c) A basic decision notice
when an oral request to withdraw an application for benefits is made.
(8) No other notice is required
when an individual completes a voluntary agreement if all of the following are met:
(a) The Authority provides
the individual with a copy of the completed agreement; and
(b) The Authority acts on
the request by the date indicated on the form.
(9) No decision notice is
required in the following situations:
(a) The only individual in
the household group dies;
(b) A hearing was requested
after a notice was received and either the hearing request is dismissed or a final
order is issued.
(10) Decision notices shall
be written in plain language and be accessible to individuals who are limited English
proficient and individuals with disabilities. In addition:
(a) All decision notices
shall include:
(A) A statement of the action
taken;
(B) A clear statement listing
the specific reasons why the decision was made and the effective date of the decision;
(C) Rules supporting the
action;
(D) Information about the
individual’s right to request a hearing and the method and deadline to request
a hearing;
(E) A statement indicating
under what circumstances a default order may be taken;
(F) Information about the
right to counsel at a hearing and the availability of free legal services;
(b) A decision notice approving
OCCS medical program benefits including retroactive medical shall include:
(A) The level of benefits
and services approved;
(B) If applicable, information
relating to premiums, enrollment fees, and cost sharing; and
(C) The changes that must
be reported and the process for reporting changes;
(c) A decision notice reducing,
denying, or closing OCCS medical program benefits shall include information about
a beneficiary’s right to continue receiving benefits.
(11) The Authority may amend:
(a) A decision notice with
another decision notice; or
(b) A contested case notice.
(12) Except as the notice
is amended, or when a delay results from the client's request for a hearing, a notice
to reduce or close benefits becomes void if the reduction or closure is not made
effective on the date stated on the notice.
(13) The Authority shall
provide individuals with a choice to receive decision notices and information referenced
in this rule in an electronic format or by postal mail. If an individual chooses
to receive notices and information electronically and has established an online
account with Cover Oregon, the Authority shall:
(a) Send confirmation of
this decision by postal mail;
(b) Post notices to the individual’s
electronic account within one business day of the date on the notice;
(c) Send an email or other
electronic communication alerting the individual that a notice has been posted to
their electronic account;
(d) At the request of the
individual, send by postal mail any notice or information delivered electronically;
(e) Inform the individual
of the right to stop receiving electronic notices and information and begin receiving
these through postal mail; and
(f) If any electronic communication
referenced above is undeliverable, send the notice by postal mail within three business
days of the failed communication.
Stat. Auth.: ORS 411.402, 411.404, 413.042
& 414.534
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231,
411.447, 414.534, 414.536 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0125
Acting on Reported Changes
(1) When an OCCS medical program beneficiary
or authorized representative makes a timely report of a change in circumstances
at any time between regular renewals of eligibility that may affect the beneficiary’s
eligibility (any changes reported per OAR410-200-0235), the Authority shall promptly
redetermine eligibility before reducing or ending medical benefits.
(2) The Authority shall limit
requests for information from the individual to information related to the reported
change.
(3) If the Authority has
enough information to determine eligibility, a new 12-month renewal period shall
be given when a redetermination results in a renewal.
(4) If the Authority has
information about anticipated changes in a beneficiary’s circumstances that
may affect eligibility, it shall redetermine eligibility at the appropriate time
based on the changes.
Stat. Auth.: ORS 411.402, 411.404, 413.042
& 414.534
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231,
411.447, 414.534, 414.536 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0130
Retroactive Medical
(1) Effective 10/01/13: The Authority
may evaluate the following for retroactive medical eligibility:
(a) Applicants requesting
OCCS medical programs may be evaluated for retroactive medical benefits if they
have unpaid medical bills or received donated medical services in Oregon in the
three months preceding the Date of Request that would have been covered by Medicaid/CHIP
benefits;
(b) Deceased individuals
who would have been eligible for Medicaid covered services had they, or someone
acting on their behalf, applied.
(2) If eligible for retroactive
medical, the individual’s eligibility may not start earlier than the date
indicated by OAR 410-200-0115 Effective Dates.
(3) The Authority reviews
each month individually for retroactive medical eligibility.
(4) Retroactive medical eligibility
may not be determined on the basis of Hospital Presumptive Eligibility (OAR 410-200-0105).
Stat. Auth.: ORS 411.402, 411.404 &
414.534
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 413.032, 414.025, 414.231, 414.534, 414.536 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0135
Assumed Eligibility and Continuous Eligibility
for Children and Pregnant Women
This rule sets out when an individual
is eligible for OCCS Medicaid/CHIP based Continuous Eligibility or being assumed
eligible as of January 1, 2014.
(1) Assumed Eligibility.
A child born to a mother eligible for and receiving Medicaid/CHIP benefits is assumed
eligible for the MAGI Child program until the end of the month in which the child
turns one year of age, unless:
(a) The child dies;
(b) The child is no longer
a resident of Oregon; or
(c) The child’s representative
requests a voluntary termination of the child’s eligibility.
(2) Continuous Eligibility
(a) Children under age 19
eligible for and receiving medical assistance under any Medicaid or CHIP program
who lose eligibility for all Medicaid or CHIP programs prior to the 12-month renewal
date shall remain eligible until the end of the renewal month, regardless of any
change in circumstances, except for the following:
(A) No longer an Oregon resident;
(B) Death;
(C) Turning age 19;
(D) For children in the CHIP
program, except as described in 410-200-0410(4), receipt of minimum essential coverage;
or
(E) When any adult in the
household group requests the medical benefits are closed;
(b) Pregnant women eligible
for and receiving medical assistance under any Medicaid program who lose eligibility
for the medical program are eligible for continuous eligibility through the end
of the calendar month in which the 60th day following the last day of the pregnancy
falls, except in the following circumstances:
(A) She is no longer an Oregon
resident;
(B) Death; or
(C) She requests medical
benefits are closed.
Stat. Auth.: ORS 411.095, 411.402, 411.404,
413.038, 414.025 & 414.534
Stats. Implemented: ORS 411.095,
411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025,
414.231, 411.447, 414.534, 414.536 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0140
Eligibility for Inmates
(1) An inmate of a public institution
may not receive benefits with OCCS medical programs.
(2) If an OCCS medical program
beneficiary becomes an inmate of a public institution with an expected stay of no
more than 12 months, medical benefits shall be suspended for up to 12 full calendar
months during the incarceration period.
(3) Suspended benefits shall
be restored to the first day the individual is no longer an inmate without the need
for a new application when:
(a) The individual reports
their release to the Agency within ten days of the release date;
(b) The individual reports
their release to the Agency more than ten days from the release date, and there
is good cause for the late reporting; or
(c) The inmate is released
to a medical facility and begins receiving treatment as an inpatient, providing
the facility is not associated with the institution where the individual was an
inmate.
(4) When released, benefits
will be restored as described in section (3), and:
(a) If the individual is
released prior to their eligibility renewal date, the eligibility renewal date will
not be changed; or
(b) If the individual is
released after the eligibility renewal date has passed, benefits will be restored
and a redetermination of eligibility processed.
Stat. Auth.: ORS 411.095, 411.402, 411.404,
413.038, 414.025 & 414.534
Stats. Implemented: ORS,
411.070, 411.404, 411.439, 411.443, 411.445, 411.816, 412.014, 412.049 & 414.426
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0145
Contested Case Hearing
(1) For the purposes of this rule, timely
means within 90 days of the date the notice of adverse action is received.
(2) This rule applies to
contested case hearings for programs described in OAR chapter 410 division 200.
Contested case hearings are conducted in accordance with the Attorney General's
model rules OAR 137-003-0501 and following ORS Ch. 183 except to the extent that
Authority rules provide for different procedures.
(3) The Authority’s
contested case hearings governed by this rule are not open to the public and are
closed to nonparticipants, except nonparticipants may attend subject to the parties'
consent and applicable confidentiality laws.
(4) A claimant may request
a contested case hearing upon the timely completion of a hearing request in medical
assistance programs in the following situations:
(a) The Authority has not
approved or denied an application within 45 days of the date of request for benefits
or the extended time the Authority has allowed for processing;
(b) The Authority acts to
deny, reduce, close, or suspend medical assistance, including the denial of continued
benefits pending the outcome of a contested case hearing;
(c) The Authority claims
that an earlier medical assistance payment was an overpayment;
(d) A claimant claims that
the Authority previously under issued medical assistance;
(e) A claimant disputes the
current level of benefits.
(5) An officer or employee
of the Authority or the Department of Human Services may appear on behalf of the
Authority in medical assistance hearings described in this rule. The Authority’s
lay representative may not make legal argument on behalf of the Authority.
(6) The Authority representative
is subject to the Code of Conduct for Non-Attorney Representatives at Administrative
Hearings, which is maintained by the Oregon Department of Justice and available
on its website at http://www.doj.state.or.us. An Authority representative appearing
under this rule shall read and be familiar with it.
(7) When an Authority representative
is used, requests for admission and written interrogatories are not permitted.
(8) The Authority representative
and the claimant may have an informal conference in order to:
(a) Provide an opportunity
to settle the matter;
(b) Review the basis for
the eligibility determination, including reviewing the rules and facts that serve
as the basis for the decision;
(c) Exchange additional information
that may correct any misunderstandings of the facts relevant to the eligibility
determination; or
(d) Consider any other matters
that may expedite the orderly disposition of the hearing.
(9) A claimant who is receiving
medical assistance benefits and who is entitled to a continuing benefit decision
notice may, at the option of the claimant, receive continuing benefits in the same
manner and amount until a final order resolves the contested case. In order to receive
continuing benefits, a claimant must request a hearing not later than:
(a) The tenth day following
the date the notice is received; and
(b) The effective date of
the action proposed in the notice.
(10) The continuing benefits
are subject to modification based on additional changes affecting the claimant’s
eligibility or level of benefits.
(11) When a claimant contests
the denial of continuing benefits, the claimant shall receive an expedited hearing.
(12) In computing timeliness
under sections (1) and (9) of this rule:
(a) Delay caused by circumstances
meeting the good cause criteria described in OAR 137-003-0501(7) may not be counted;
and
(b) The notice is considered
to be received on the fifth day after the notice is sent unless the claimant shows
the notice was received later or was not received.
Stat. Auth.: ORS 411.404, 411.816, 412.014,
412.049 & 413.042
Stats. Implemented: ORS 183.452,
411.060, 411.404, 411.816, 412.014 & 412.049
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 50-2014(Temp), f. 8-14-14,
cert. ef. 8-15-14 thru 2-11-15; DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14
thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0146
Final Orders, Dismissals and Withdrawals
(1) When the Authority refers a contested
case under chapter 410 division 200 to the Office of Administrative Hearings (OAH),
the Authority must indicate on the referral:
(a) Whether the Authority
is authorizing a proposed order, a proposed and final order, or a final order; and
(b) If the Authority establishes
an earlier deadline for written exceptions and argument because the contested case
is being referred for an expedited hearing.
(2) When the Authority authorizes
either a proposed order or a proposed and final order:
(a) The claimant may file
written exceptions and written argument to be considered by the Authority. The exceptions
and argument must be received at the location indicated in the OAH order not later
than the 20th day after service of the proposed order or proposed and final order,
unless section (1)(b) of this rule applies;
(b) The Authority shall issue
the final order after OAH issues a proposed order unless the Authority requests
that OAH issue the final order pursuant to OAR 137-003-0655.
(c) The proposed and final
order becomes a final order on the 21st day after the service of the proposed and
final order, if the claimant does not submit timely exceptions or arguments following
a proposed and final order, unless:
(A) The Authority has issued
a revised order; or
(B) The Authority has notified
the claimant and OAH that the Authority shall issue the final order.
(d) The Authority shall issue
the final order when the Authority receives timely exceptions or argument unless
the Authority requests that OAH issue the final order.
(3) In a contested case hearing,
if the OAH is authorized to issue a final order on behalf of the Authority, the
Authority may issue the final order in the case of default.
(4) A petition by a claimant
for reconsideration or rehearing must be filed with the individual who signed the
final order unless stated otherwise on the final order.
(5) A final order is effective
immediately upon being signed or as otherwise provided in the order. Delay due to
a postponement or continuance granted at the claimant’s request may not be
counted in computing time limits for a final order. A final order shall be issued
or the case otherwise shall be resolved no later than:
(a) Ninety days following
the date of the hearing for the standard hearing time frame;
(b) Three working days after
the date the OAH hears an expedited hearing.
(6) In the event a request
for a hearing is not timely or the claimant has no right to a contested case hearing
on an issue, and there are no factual disputes about whether this division of rules
provides a right to a hearing, the Authority may issue an order accordingly. The
Authority may refer an untimely request to the OAH for a hearing on timeliness or
on the question of whether the claimant has the right to a contested case hearing.
(7) If the Authority serves
a decision notice on the claimant by postal or electronic mail and the Authority
receives an untimely hearing request from the claimant within 75 days from the date
the decision notice became a final order, then one of the following shall occur:
(a) If the Authority finds
that the claimant did not receive the decision notice and did not have actual knowledge
of the notice, the Authority shall refer the hearing request to the OAH for a contested
case hearing on the merits of the Authority’s action described in the notice;
or
(b) If there is a factual
dispute regarding the claimant’s receipt or knowledge of the notice, the Authority
shall refer the hearing request to the OAH for a contested case hearing to determine
whether the claimant received or had actual knowledge of the notice. The Authority
has the burden to prove by a preponderance of the evidence that the claimant had
actual knowledge of the notice or that the Authority mailed the notice to the claimant’s
correct mailing address or sent an electronic notice to the claimant’s correct
electronic mail address according to the information the claimant provided to the
Authority.
(8) If the Authority receives
an untimely hearing request from the claimant, regardless of the manner in which
the Authority served the decision notice on the claimant, then:
(a) If the Authority finds
that the claimant’s hearing request was untimely for good cause as defined
in OAR 137-003-0501(7), the Authority shall refer the hearing request to the OAH
for a contested case hearing on the merits of the Authority’s action described
in the notice; or
(b) If there is a factual
dispute regarding the existence of good cause, the Authority shall refer a hearing
request to the OAH for a contested case hearing to determine whether there was good
cause as defined in OAR 137-003-0501(7) for the claimant’s delay in submitting
the hearing request to the Authority.
(c) Any hearing request is
treated as timely when required under the Servicemembers Civil Relief Act.
(d) The Authority may dismiss
a hearing request as untimely if the claimant does not qualify for a hearing under
sections (8)(a), (b), or (c).
(9) A claimant may withdraw
a hearing request at any time before a final order has been issued on the contested
case. When a claimant withdraws a hearing request:
(a) The Authority shall send
an order confirming the withdrawal to the claimant’s last known address;
(b) The claimant may cancel
the withdrawal in writing. The withdrawal must be received by the Authority hearing
representative no later than the tenth working day following the date the Authority
sent the order confirming the withdrawal.
(10) A hearing request is
dismissed by order by default when neither the claimant nor the claimant’s
representative appears at the time and place specified for the hearing. The order
is effective on the date scheduled for the hearing. The Authority shall cancel the
dismissal order on request of the claimant on a showing that the claimant was unable
to attend the hearing and unable to request a postponement due to circumstances
meeting the good cause criteria described in OAR 137-003-0501(7).
Stat. Auth.: ORS 183.341, 413.042, 411.060,
411.404, 411.408, 411.816, 412.014 & 412.049
Stats. Implemented: ORS 183.341,
411.060, 411.404, 411.408, 411.816, 412.014 & 412.049
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 50-2014(Temp), f. 8-14-14,
cert. ef. 8-15-14 thru 2-11-15; DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14
thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0200
Residency Requirements
(1) To be eligible for OCCS medical
programs, an individual must be a resident of Oregon.
(2) An individual is a resident
of Oregon if the individual lives in Oregon except:
(a) An individual 21 years
of age or older who is placed in a medical facility in Oregon by another state is
considered to be a resident of the state that makes the placement if:
(A) The individual is capable
of indicating intent to reside; or
(B) The individual became
incapable of indicating intent to reside after attaining 21 years of age (see section
(6));
(b) For an individual less
than 21 years of age who is incapable of indicating intent to reside or an individual
of any age who became incapable of indicating that intent before attaining 21 years
of age, the state of residence is one of the following:
(A) The state of residence
of the individual's parent or legal guardian at the time of application;
(B) The state of residence
of the party who applies for benefits on the individual's behalf if there is no
living parent or the location of the parent is unknown, and there is no legal guardian;
(C) Oregon, if the individual
has been receiving medical assistance in Oregon continuously since November 1, 1981,
or is from a state with which Oregon has an interstate agreement that waives the
residency requirement;
(D) When a state agency of
another state places the individual, the individual is considered to be a resident
of the state that makes the placement.
(3) There is no minimum amount
of time an individual must live in Oregon to be a resident. The individual is a
resident of Oregon if:
(a) The individual intends
to remain in Oregon; or
(b) The individual entered
Oregon with a job commitment or is looking for work.
(4) An individual is not
a resident if the individual is in Oregon solely for a vacation.
(5) An individual continues
to be a resident of Oregon during a temporary period of absence if he or she intends
to return when the purpose of the absence is completed.
(6) An individual is presumed
to be incapable of indicating intent to reside if the individual falls under one
or more of the following:
(a) The individual is assessed
with an IQ of 49 or less based on a test acceptable to the Authority;
(b) The individual has a
mental age of seven years or less based on tests acceptable to the Authority;
(c) The individual is judged
legally incompetent by a court of competent jurisdiction;
(d) The individual is found
incapable of indicating intent to reside based on documentation provided by a physician,
psychologist, or other professional licensed by the State of Oregon in the field
of intellectual disabilities.
Stat. Auth.: ORS 411.402, 411.404, 413.042
& 414.534
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231,
411.447, 414.534, 414.536 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0205
Concurrent and Duplicate Program Benefits
(1) An individual receiving OCCS medical
program benefits may not receive the following medical benefits at the same time:
(a) Any other OCCS medical
program;
(b) Office of Child Welfare
Medical;
(c) Oregon Youth Authority
Medical;
(d) Oregon Supplemental Income
Program-Medical (OSIPM); or
(e) Refugee Medical Assistance
(REFM);
(2) An individual may not
receive OCCS medical program benefits and medical benefits from another state unless
the individual’s provider refuses to submit a bill to the Medicaid/CHIP agency
of the other state and the individual would not otherwise receive medical care.
Stat. Auth.: ORS 411.402, 411.404, 413.042
& 414.534
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231,
411.447, 414.534, 414.536 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0210
Requirement to Provide Social Security
Number
(1) The Agency may collect a Social
Security Number (SSN) for the following purposes:
(a) The determination of
eligibility for benefits. The SSN is used to verify income and other assets and
to match with other state and federal records such as the Internal Revenue Service
(IRS), Medicaid, spousal support, Social Security benefits, and unemployment benefits;
(b) The preparation of aggregate
information and reports requested by funding sources for the program providing benefits;
(c) The operation of the
program applied for or providing benefits;
(d) Conducting quality assessment
and improvement activities;
(e) Verifying the correct
amount of payments, recovering overpaid benefits, and identifying any individual
receiving benefits in more than one household.
(2) As a condition of eligibility,
except as provided in section (6) below, each applicant (including children) requesting
medical benefits shall:
(a) Provide a valid SSN;
or
(b) Apply for an SSN if the
individual does not have one and provide the SSN when it is received.
(3) The agency may not deny
or delay services to an otherwise eligible individual pending issuance or verification
of the individual’s SSN or if the individual meets one of the exceptions identified
in section (6).
(4) Except as provided in
section (6) below, if an applicant does not recall their SSN or has not been issued
an SSN and the SSN is not available to the Agency, the Agency shall:
(a) Obtain required evidence
under SSA regulations to establish the age, the citizenship, or alien status and
the true identity of the applicant; and
(b) Either assist the applicant
in completing an application for an SSN or, if there is evidence that the applicant
has previously been issued an SSN, request SSA to furnish the number.
(5) The Agency may request
that non-applicants provide an SSN on a voluntary basis. The Agency shall use the
SSN for the purposes outlined in section (1).
(6) An applicant is not required
to apply for or provide an SSN if the individual:
(a) Does not have an SSN
and the SSN may be issued only for a valid-non-work reason;
(b) Is not eligible to receive
an SSN;
(c) Is a member of a religious
sect or division of a religious sect that has continuously existed since December
31, 1950 and the individual adheres to its tenets or teachings that prohibit applying
for or using an SSN; or
(d) Is a newborn that is
assumed eligible based on the eligibility of the mother of the newborn and who is
under one year of age.
Stat. Auth.: ORS 411.402, 411.404, 413.042
& 414.534
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 413.032, 413.038, 414.025, 414.231, 414.534, 414.536
& 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0215
Citizenship and Alien Status Requirements
(1) Except as provided in section (2)
of this rule, to be a beneficiary of a medical program an individual must be:
(a) A citizen of the United
States;
(b) A non-citizen who meets
the alien status requirements in section (4) of this rule;
(c) A citizen of Puerto Rico,
Guam, the Virgin Islands or Saipan, Tinian, Rota or Pagan of the Northern Mariana
Islands; or
(d) A national from American
Samoa or Swains Islands.
(2) To be eligible for CAWEM
benefits, an individual must be ineligible for a Medicaid program solely because
he or she does not meet citizenship or alien status requirements set forth in this
rule.
(3) An individual is a qualified
non-citizen if the individual is any of the following:
(a) A non-citizen lawfully
admitted for permanent residence under the INA (8 U.S.C. 1101 et seq);
(b) A refugee admitted to
the United States as a refugee under section 207 of the INA (8 U.S.C. 1157);
(c) A non-citizen granted
asylum under section 208 of the INA (8 U.S.C. 1158);
(d) A non-citizen whose deportation
is being withheld under section 243(h) of the INA (8 U.S.C. 1253(h)) (as in effect
immediately before April 1, 1997) or section 241(b)(3) of the INA (8 U.S.C. 1231(b)(3))
(as amended by section 305(a) of division C of the Omnibus Consolidated Appropriations
Act of 1997, Pub. L. No. 104-208, 110 Stat. 3009-597 (1996));
(e) A non-citizen paroled
into the United States under section 212(d)(5) of the INA (8 U.S.C. 1182(d)(5))
for a period of at least one year;
(f) A non-citizen granted
conditional entry pursuant to section 203(a) (7) of the INA (8 U.S.C. 1153(a) (7))
as in effect prior to April 1, 1980;
(g) A non-citizen who is
a Cuban and Haitian entrant (as defined in section 501(3) of the Refugee Education
Assistance Act of 1980);
(h) An Afghan or Iraqi alien
granted Special Immigration Status (SIV) under section 101(a) (27) of the INA; or
(i) A battered spouse or
child who meets the requirements of 8 U.S.C. 1641(c) and is in the United States
on a conditional resident status, as determined by the U.S. Citizenship and Immigration
Services.
(4) A non-citizen meets the
alien status requirements if the individual is:
(a) An American Indian born
in Canada to whom the provisions of section 289 of the Immigration and Nationality
Act (INA) (8 U.S.C. 1359) apply;
(b) A member of an Indian
tribe, as defined in section 4(e) of the Indian Self-Determination and Education
Act (25 U.S.C. 450b(e));
(c) A veteran of the United
States Armed Forces who was honorably discharged for reasons other than alien status
and who fulfilled the minimum active-duty service requirements described in 38 U.S.C.
5303A(d);
(d) A member of the United
States Armed Forces on active duty (other than active duty for training);
(e) The spouse or a child
of an individual described in subsection (c) or (d) of this section.
(f) A qualified non-citizen
and meets one of the following criteria:
(A) Effective October 1,
2009 is an individual under 19 years of age;
(B) Was a qualified non-citizen
before August 22, 1996;
(C) Physically entered the
United States before August 22, 1996, and was continuously present in the United
States between August 22, 1996, and the date qualified non-citizen status was obtained.
An individual is not continuously present in the United States if the individual
is absent from the United States for more than 30 consecutive days or a total of
more than 90 days between August 22, 1996 and the date qualified non-citizen status
was obtained.;
(D) Has been granted any
of the following alien statuses:
(i) Refugee under section
207 of the INA;
(ii) Asylum under section
208 of the INA;
(iii) Deportation being withheld
under section 243(h) of the INA;
(iv) Cubans and Haitians
who are either public interest or humanitarian parolees;
(v) An individual granted
immigration status under section 584(a) of the Foreign Operations, Export Financing
and Related Program Appropriations Act of 1988;
(vi) A "victim of a severe
form of trafficking in persons" certified under the Victims of Trafficking and Violence
Protection Act of 2000 (22 U.S.C. 7101 to 7112;
(vii) A family member of
a victim of a severe form of trafficking in persons who holds a visa for family
members authorized by the Trafficking Victims Protection Reauthorization Act of
2003 (22 U.S.C. 7101 to 7112);
(viii) An Iraqi or Afghan
alien granted special immigrant status (SIV) under section 101(a) (27) of the INA;
(g) Under the age of 19 and
is one of the following:
(A) A citizen of a Compact
of Free Association State (i.e., Federated States of Micronesia, Republic of the
Marshall Islands, and the Republic of Palau) who has been admitted to the U.S. as
a non-immigrant and is permitted by the Department of Homeland Security to reside
permanently or indefinitely in the U.S;
(B) An individual described
in 8 CFR section 103.12(a)(4) who belongs to one of the following classes of aliens
permitted to remain in the United States because the Attorney General has decided
for humanitarian or other public policy reasons not to initiate deportation or exclusion
proceedings or enforce departure:
(i) An alien currently in
temporary resident status pursuant to section 210 or 245A of the INA (8 USC 1160
and 1255a);
(ii) An alien currently under
Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 USC 1229b);
(iii) Cuban-Haitian entrants,
as defined in section 202(b) Pub. L. 99–603 (8 USC 1255a), as amended;
(iv) Family Unity beneficiaries
pursuant to section 301 of Pub. L. 101–649 (8 USC 1255a), as amended;
(v) An alien currently under
Deferred Enforced Departure (DED) pursuant to a decision made by the President;
(vi) An alien currently in
deferred action status pursuant to Department of Homeland Security Operating Instruction
OI 242.1(a) (22); or
(vii) An alien who is the
spouse or child of a United States citizen whose visa petition has been approved
and who has a pending application for adjustment of status;
(C) An individual in non-immigrant
classifications under the INA who is permitted to remain in the U.S. for an indefinite
period, including those individuals as specified in section 101(a)(15) of the INA
(8 USC 1101);
(D) An alien in non-immigrant
status who has not violated the terms of the status under which he or she was admitted
or to which he or she has changed after admission;
(E) Aliens who have been
granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20),
(22), or (24);
(F) A pending applicant for
asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding
of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the
Convention Against Torture who has been granted employment authorization, and such
an applicant under the age of 14 who has had an application pending for at least
180 days;
(G) An alien who has been
granted withholding of removal under the Convention Against Torture;
(H) A child who has a pending
application for Special Immigrant Juvenile status as described in section 101(a)(27)(J)
of the INA (8 U.S.C. § 1101(a)(27)(J));
(I) An alien who is lawfully
present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. §
1806(e); or
(J) An alien who is lawfully
present in American Samoa under the immigration laws of American Samoa.
(5) Individuals described
in sections (3)(a), (3)(e), (3)(f), and (3)(i) of this rule who entered the United
States or were given qualified non-citizen status on or after August 22, 1996 meet
the alien status requirement five years following the date the non-citizen received
the qualified non-citizen status.
(6) Individuals described
in sections (3)(a) through (g), (3)(i), (4)(g)(B)(ii), (4)(g)(B)(iv), (4)(g)(B)(v),
(4)(g)(B)(vii), and (4)(g)(D) through (J) with deferred action under Deferred Action
for Childhood Arrivals (DACA) process do not meet the non-citizen requirement for
OCCS medical programs.
Stat. Auth.: ORS 411.402, 411.404, 413.042
& 414.534
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 413.032, 414.025, 414.231, 414.534, 414.536 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0220
Requirement to Pursue Assets
(1) As a condition of on-going eligibility,
an applicant or beneficiary shall make a good faith effort to obtain an asset to
which they have a legal right or claim, except an applicant or beneficiary is not
required to:
(a) Apply for Supplemental
Security Income (SSI) from the Social Security Administration;
(b) Borrow money;
(c) Make a good faith effort
to obtain such asset if the individual can show good cause for not doing so (see
section (4).
(2) Pursuable assets include,
but are not limited to:
(a) Claims related to an
injury;
(b) Disability benefits;
(c) Healthcare coverage;
(d) Retirement benefits;
(e) Survivorship benefits;
(f) Unemployment compensation;
and
(g) Veteran’s compensation
and pensions.
(3) Except for beneficiaries
in the OHP-CHP or MAGI CHIP programs, caretakers shall obtain available health insurance
coverage and cash medical support for household group members receiving medical
assistance:
(a) Each caretaker in the
household group shall assist the Agency and the Division of Child Support (DCS)
in establishing paternity for each child receiving medical assistance and in obtaining
an order directing the non-custodial parent of a child receiving benefits to provide
cash medical support and health care coverage for that child;
(b) For a parent receiving
medical assistance who fails to meet the requirements of section (3) (a), a penalty
is applied as identified in section (3) (e) or section (3) (f) after providing the
beneficiary with notice and opportunity to show the provisions of section (4) of
this rule apply;
(c) Each applicant, including
a parent for their child, shall make a good faith effort to obtain available coverage
under Medicare. The Authority may not penalize children for non-cooperation;
(d) With the exception of
OHP-CHP, MAGI CHIP, and OHP-OPU, caretakers who are OCCS medical program beneficiaries
shall apply for, accept, and maintain cost-effective employer-sponsored health insurance
as set forth in OAR 461-155-0360 unless they have good cause;
(e) For MAA, MAF, EXT, CEM,
and Substitute Care medical programs, a parent who fails to meet the requirements
of section (3) is excluded from the family size;
(f) With the exception of
OHP-CHP, MAGI-CHIP, and CEC, a parent of a child receiving OCCS medical program
benefits who fails to meet the requirements of section (3) is ineligible for assistance.
(4) Section (3) of this rule
does not apply to individuals when:
(a) The individual’s
compliance would result in emotional or physical harm to the dependent child or
to the caretaker. The statement of the caretaker serves as prima facie evidence
that harm would result;
(b) The child was conceived
as a result of incest or rape and efforts to obtain support would be detrimental
to the dependent child. The statement of the caretaker serves as prima facie evidence
on the issues of conception and detrimental effect to the dependent child;
(c) Legal proceedings are
pending for adoption of the child;
(d) The parent is being helped
by a public or licensed private social agency to resolve the issue of whether to
release the child for adoption;
(e) The individual is pregnant;
or
(f) Other good cause reasons
exist for non-cooperation.
(5) An individual involved
in a personal injury shall pursue a claim for the personal injury. If the claim
or action to enforce such claim was initiated prior to the application for medical
assistance, the individual shall notify the Agency during the eligibility verification
process (OAR 410-200-0230). The following information is required:
(a) The names and addresses
of all parties against whom the action is brought or claim is made;
(b) A copy of each claim
demand; and
(c) If an action is brought,
the case number and the county where the action is filed.
(6) Unless specified otherwise
in this rule, an individual who fails to comply with the requirements of this rule
is ineligible for benefits until the individual meets the requirements of this rule.
Stat. Auth.: ORS 411.402, 411.404 &
413.042
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 413.032, , 414.025, 414.231 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0225
Assignment of Rights
(1) The signature of the applicant or
authorized representative on the application for assistance signifies the applicant’s
agreement to assign the rights to reimbursement for medical care costs to the Agency.
(2) As a condition of eligibility,
each applicant shall:
(a) Assign to the Agency
any rights of each household group member receiving benefits to reimbursement for
medical care costs to the Agency including any third party payments for medical
care and any medical care support available under an order of a court or an administrative
agency;
(b) Assign to the Agency
any rights to payment for medical care from any third party and, once they receive
assistance, to assist the Agency in pursuing any third party who may be liable for
medical care or services paid by the Agency, including health services paid for
pursuant to ORS 414.706 to 414.750 as set forth in OAR 410-200-0220, 461-195-0303
and 461-195-0310;
(c) Unless good cause exists
as established in OAR 410-200-0220 (Requirement to Pursue Assets), failure to assign
the right to reimbursement for medical care costs to the Agency shall result in
ineligibility for the household group until the requirements of this rule are met.
(3) Except for the OHP-OPU,
OHP-CHP, and MAGI CHIP programs:
(a) An applicant shall assign
to the state the right of any Medicaid-eligible individual in the household group
to receive any cash medical support that accrues while the individual receives assistance,
not to exceed the total amount of assistance paid; and
(b) Cash medical support
received by the Agency shall be retained as necessary to reimburse the Agency for
medical assistance payments made on behalf of an individual with respect to whom
such assignment was executed.
Stat. Auth.: ORS 411.402, 411.404 &
413.042
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 413.032, , 414.025, 414.231 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0230
Verification
(1) Except as described in section (6)
of this rule, applicants, beneficiaries, or individuals of the applicant or beneficiary’s
choosing shall attest to the following information:
(a) Age and date of birth;
(b) Application for other
benefits;
(c) Caretaker relative status;
(d) Household composition;
(e) Legal name;
(f) Medicare;
(g) Pregnancy;
(h) Receipt or availability
of other healthcare coverage;
(i) Residency;
(j) Social Security number;
and
(k) American Indian/Alaska
Native status.
(2) Applicants and beneficiaries
who attest to US citizenship or US national status:
(a) Applicants, beneficiaries,
or individuals of the applicant or beneficiary’s choosing shall make a declaration
of US citizenship or US national status;
(b) Self-attested information
shall be used to determine eligibility and verified post-eligibility via the federal
data services hub or by electronic data match available to the Agency;
(c) In the event additional
verification is needed, the Authority shall provide a reasonable opportunity period
to verify US citizen or US national status.
(3) Applicants and beneficiaries
who attest to being a non-citizen:
(a) Applicants, beneficiaries,
or individuals of the applicant or beneficiary’s choosing shall make a declaration
of non-citizen status:
(A) If an individual attests
to being a non-citizen but does not provide information regarding their status,
information shall be obtained by the Agency prior to making an eligibility determination;
(B) Self-attested information
shall be used to approve OCCS Medicaid/CHIP as long as the information provided
is considered satisfactory immigration status:
(i) The application is not
considered incomplete even if the information provided does not include all the
immigration information necessary to verify that the applicant meets Medicaid/CHIP
non-citizen requirements; and
(ii) The information provided
does not indicate that the applicant would be ineligible for full benefits;
(C) If information provided
indicates the individual does not meet the Medicaid/CHIP non-citizen requirements,
an otherwise eligible applicant shall be found eligible for CAWEM (OAR 410-200-0240);
(b) In the event additional
verification is needed, the Authority shall provide a reasonable opportunity period
to verify non-citizen status;
(c) The following are exempt
from the requirement to verify citizen status:
(A) Individuals who are assumed
eligible (OAR 410-200-0135);
(B) Individuals who are enrolled
in Medicare;
(C) Individuals who are presumptively
eligible for the BCCTP program through the BCCTP screening program or through the
Hospital Presumptive Eligibility process (OAR 420-200-0400 and 410-200-0105);
(D) Individuals receiving
Social Security Disability Income (SSDI); or
(E) Individuals whose citizen
status was previously documented by the Agency. The Agency may not re-verify or
require an individual to re-verify citizenship at a renewal of eligibility or subsequent
application following a break in coverage;
(d) Non-citizen status shall
be reviewed and verified at the following times:
(A) Initial determination
of eligibility;
(B) Each redetermination
of eligibility; or
(C) When a report of change
of non-citizen status is received by the Agency.
(4) Applicants, beneficiaries,
or individuals of the applicant or beneficiary’s choosing shall make a declaration
of income:
(a) For individuals whose
request for benefits is able to be processed using the federal data services hub,
self-attested information shall be used to approve MAGI-based Medicaid/CHIP, and:
(A) Verified by documentary
evidence through a match with available electronic data; or
(B) In the event that additional
verification is needed, the Authority shall provide a post-eligibility pend period
to verify income information;
(b) Individuals whose request
for benefits is not able to be processed using the federal data services hub shall
have their income information verified prior to eligibility determination:
(A) Using electronic data
match available to the Agency; or
(B) By providing verification
of information to the Agency;
(c) In the event that verification
is not available via the federal data services hub, electronic data match available
to the Agency, or by any other method, the attested information will be accepted
to determine eligibility;
(d) In the event that income
verification via the federal data services hub or electronic data match available
to the Agency is inconsistent with attested information:
(A) If the individual attests
to income below the applicable standard and the data source indicates income above
the applicable standard, verification or reasonable explanation will be requested
from the individual;
(B) If both the data source
and attested information are below the applicable standard, the applicant is eligible
for MAGI-based Medicaid/CHIP;
(C) If the individual’s
attested information is above the applicable standard but the data source verification
is below the standard, the Agency will accept the attested information, deny MAGI-based
Medicaid/CHIP, and screen for potential APTC eligibility.
(5) Additional income verifications
for MAGI-based Medicaid/CHIP program approvals will occur during the post-eligibility
review process, during which the results of a quarterly match against Employment
Department wage data will be reviewed as it becomes available. If necessary, documentation
may be required per section (6).
(6) Applicants, beneficiaries,
or individuals of the applicant or beneficiary’s choosing shall make a declaration
of receipt of private health insurance:
(a) For individuals whose
request for benefits is able to be processed using the federal data services hub:
(A) Self-attested information
shall be used to determine eligibility for MAGI-based Medicaid/CHIP if:
(i) Information obtained
through a match with available electronic data does not conflict with self-attested
information;
(ii) Information obtained
through a match with available electronic data conflicts with self-attested information
but does not affect eligibility; or
(iii) Verification is not
available via a match with available electronic data or by any other method at the
time of application processing;
(B) In the event that information
obtained through a match with available electronic data conflicts with self-attested
information and may affect eligibility, private health insurance information shall
be verified prior to eligibility determination;
(b) Individuals whose request
for benefits is not able to be processed using the federal data services hub who
attest to private health insurance information that may affect eligibility shall
have their private health insurance information verified prior to eligibility determination:
(A) Using electronic data
match available to the Agency; or
(B) By providing verification
of information to the Agency.
(7) The Authority may request
that applicants and beneficiaries of medical assistance provide additional information,
including documentation, to verify most eligibility criteria if data obtained electronically
is not reasonably compatible with attested information.
Stat. Auth.: ORS 411.402, 411.404, 413.042
& 414.534
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231,
411.447, 414.534, 414.536 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0235
Changes That Must Be Reported
(1) Individuals shall report the following
changes in circumstances affecting eligibility for beneficiaries within 30 calendar
days of its occurrence:
(a) The receipt or loss of
health care coverage;
(b) A change in mailing address
or residence;
(c) A change in legal name;
(d) A change in pregnancy
status of a household group member;
(e) A change in household
group membership;
(f) A claim for a personal
injury. The following information shall be reported:
(A) The names and addresses
of all parties against whom the action is brought or claim is made;
(B) A copy of each claim
demand; and
(C) If an action is brought,
identification of the case number and the county where the action is filed;
(g) In addition to section
(1)(a)–(f), for all OCCS medical programs except OHP-CHP and MAGI CHIP, a
change in availability of employer-sponsored health insurance;
(h) In addition to section
(1)(a)–(f), in the EXT program, when a household group member receiving medical
assistance is no longer a dependent child;
(i) In addition to section
(1)(a)–(f), adults in the MAA, MAF, EXT, MAGI Pregnant Woman, MAGI Parent
or Other Caretaker Relative, and MAGI Adult programs:
(A) A change in source of
income;
(B) A change in employment
status;
(i) For a new job, the change
occurs the first day of the new job;
(ii) For a job separation,
the change occurs on the last day of employment;
(C) A change in earned income
more than $100. The change occurs upon the receipt by the beneficiary of the first
paycheck from a new job or the first paycheck reflecting a new rate of pay;
(D) A change in unearned
income more than $50. The change occurs the day the beneficiary receives the new
or changed payment.
(2) Beneficiaries, adult
members of the household group, or authorized representatives may report changes
via the Internet, by telephone, via mail, in person, and through other commonly
available electronic means.
(3) A change is considered
reported on the date the beneficiary, adult member of the household group, or authorized
representative reports the information to the Agency.
(4) A change reported by
the beneficiary, adult member of the household group, or authorized representative
for one program is considered reported for all programs administered by the Agency
in which the beneficiary participates.
(5) Beneficiaries, adult
members of the household group, or authorized representatives are not required to
report any of the following changes:
(a) Periodic cost-of-living
adjustments to the federal Black Lung Program, SSB, SSDI, SSI, and veterans assistance
under Title 38 of the United States Code;
(b) Changes in eligibility
criteria based on legislative or regulatory actions.
Stat. Auth.: ORS 411.402, 411.404, 413.042
& 414.534
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 414.025, 414.231, 411.447,
414.534, 414.536 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0240
Citizen/Alien Waived Emergent Medical
(1) To be eligible for CAWEM benefits,
an individual must be ineligible for OCCS medical programs solely because he or
she does not meet the citizen or alien status requirements. A child who is ineligible
for OHP-CHP, MAGI CHIP, CEM, or CEC solely because he or she does not meet the citizen
or alien status requirements is not eligible for CAWEM benefits.
(2) To be eligible for the
CAWEM Prenatal enhanced benefit package, a CAWEM recipient must be pregnant.
(3) The pregnant CAWEM client’s
enhanced medical benefits package ends when the pregnancy ends.
(4) The woman remains eligible
for CAWEM emergency benefits through the end of the calendar month in which the
60th day following the last day of the pregnancy falls.
Stat. Auth.: ORS 411.402, 411.404, 413.042,
414.025 & 414.534
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 414.025, 414.231, 411.447,
414.534, 414.536, 414.706 & 411.060
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0305
Household Group — Modified Adjusted
Gross Income (MAGI) based Medicaid and CHIP
When establishing eligibility for MAGI-based
Medicaid or MAGI CHIP, each applicant or beneficiary shall have their own household
group determined individually based on the following household group rules:
(1) Tax filer’s household
group:
(a) For tax filers who are
not claimed as a tax dependent by another individual, the household group consists
of:
(A) The tax filer;
(B) The individual to whom
the tax filer is married and files jointly; and
(C) All individuals whom
the tax filer intends to claim as tax dependents.
(b) For tax filers who are
married and living with their spouse, each spouse shall be included in the household
group of the other spouse, whether they file taxes together or separately.
(2) Tax dependent’s
household group:
(a) In the case of an individual
who expects to be claimed as a tax dependent by another individual, the household
group is that of the individual claiming the tax dependent; or
(b) Household group is determined
under section (3) of this rule, where the tax dependent:
(A) Is not the tax filer’s
spouse or child;
(B) Is a child living with
both parents but the parents are not filing taxes jointly and one of the parents
is claiming the child as a tax dependent; or
(C) Is a child living with
one parent and claimed as a tax dependent by a non-custodial parent.
(3) The household group for
a tax dependent who meets the criteria in section (2) (b) consists of the tax dependent
and the following individuals, if living in the same household:
(a) The tax dependent’s
spouse;
(b) The tax dependent’s
children;
(c) If the tax dependent
is a child, the child’s parents and siblings.
(4) For individuals who do
not file a tax return and are not claimed as a tax dependent, the individual’s
household group is determined in accordance with section (3).
Stat. Auth.: ORS 411.402, 411.404 &
413.042
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 414.025, 414.231, 411.447
& 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0310
Eligibility and Budgeting; MAGI Medicaid/CHIP;
Not BCCTP or EXT
(1) The budget month means the calendar
month from which nonfinancial and financial information is used to determine eligibility
for OCCS medical programs.
(2) The budget month is determined
as follows:
(a) For a new applicant,
the budget month is:
(A) The month in which medical
assistance is requested; or
(B) If ineligible in the
month in which medical assistance is requested, the budget month is the following
month;
(b) For a current Medicaid/CHIP
beneficiary, the budget month is:
(A) The final month of the
twelve-month enrollment period;
(B) The month a change that
affects eligibility is reported, if reported timely; or
(C) The month the individual
ages off a medical program or is no longer eligible for a medical assistance program;
(c) For retroactive medical,
the budget month is the month in which the applicant received medical services for
which they are requesting payment. Retroactive medical is determined on a month-by-month
basis.
(3) Countable income anticipated
or received in the budget month is determined as follows:
(a) Income is calculated
by adding together the income of the household group already received in the initial
budget month and the income that is reasonably expected to be received in the remainder
of the initial budget month;
(b) If ineligible using the
initial budget month because the countable income is over the income standard for
all OCCS medical programs, income shall be annualized using the requirements of
25 CFR §1.36 B-1(e) for the year in which medical has been requested:
(A) Annualized income will
be applied to the budget month for budget month eligibility.
(B) If the annualized income
is below 100 percent FPL as identified in 26 CFR §1.36 B-1(e), eligibility
shall be determined for the appropriate program pursuant to OAR 410-200-0315;
(c) If ineligible under subsections
(a) or (b) of this section, countable income from the month following the initial
budget month is considered. If eligible, eligibility will begin the first of that
month of an OCCS medical program
(4) The household group’s
budget month income is compared to the income standard for the appropriate family
size to determine if an applicant may be eligible for an OCCS medical program.
Stat. Auth.: ORS 411.402, 411.404 &
413.042
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, , 414.025, 414.231, 411.447
& 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0315
Standards and Determining Income Eligibility
(1) MAGI-based income not specifically
excluded is countable, and its value is used in determining the eligibility and
benefit level of an applicant or beneficiary.
(2) MAGI-based income is
considered available on the date it is received or the date a member of the household
group has a legal right to the payment and the legal ability to make it available,
whichever is earlier, except as follows:
(a) Income usually paid monthly
or on some other regular payment schedule is considered available on the regular
payment date if the date of payment is changed because of a holiday or weekend;
(b) Income withheld or diverted
at the request of an individual is considered available on the date the income would
have been paid without the withholding or diversion;
(c) An advance or draw of
earned income is considered available on the date it is received.
(3) In determining financial
eligibility for each applicant, the sum of the budget month MAGI-based income of
all household group members is combined and compared to the applicable income standard
for the family size. If the income is at or below the MAGI income standard, the
individual meets the financial eligibility requirements. Except as provided in section
(4)(a), if income exceeds the MAGI income standard, the individual is ineligible.
(4) This section applies
to MAGI Medicaid/CHIP programs:
(a) If an individual is ineligible
for MAGI Medicaid based solely on income and would otherwise be eligible for MAGI
CHIP or be referred to the Exchange for APTC, a disregard equivalent to five percentage
points of the federal poverty level for the applicable family size shall be applied
to the household group’s income. If the resulting amount is below the income
standard for the applicable program and family size, the individual meets the financial
eligibility requirements in the following programs:
(A) The MAGI Parent or Other
Caretaker Relative Program;
(B) The MAGI Child Program;
(C) The MAGI Adult Program;
and
(D) The MAGI Pregnant Woman
Program;
(b) If an individual is ineligible
for MAGI CHIP based solely on income and would otherwise be referred to the Exchange
for APTC, a disregard equivalent to five percentage points of the federal poverty
level for the applicable family size shall be applied to the household group’s
income. If the resulting amount is below the income standard for the applicable
program and family size, the individual meets the financial eligibility requirements
in the MAGI CHIP;
(c) The MAGI income standard
for the MAGI Parent or Other Caretaker-Relative program is set as follows: [Table
not included. See ED. NOTE.]
(d) Effective March 1, 2015,
the MAGI income standard for the MAGI Child Program and the MAGI Adult Program is
set at 133 percent of the FPL as follows. If an individual’s household group
income exceeds the income standard for their family size, the appropriate disregard
for their family size described in section (4)(a) shall be applied: [Table not included.
See ED. NOTE.]
(e) Effective March 1, 2015,
the MAGI income standard for the MAGI Pregnant Woman Program and for MAGI Child
Program recipients under age one is set at 185 percent FPL. If an individual’s
household group income exceeds the income standard for their family size, the appropriate
disregard for their family size described in section (4)(a) shall be applied: [Table
not included. See ED. NOTE.]
(f) Effective March 1, 2015,
the MAGI income standard for the MAGI CHIP program is set through 300 percent of
FPL as follows. If a child’s household group income exceeds the income standard
for their family size, and the child would be otherwise ineligible for MAGI CHIP,
the appropriate disregard for their family size described in section (5)(a)(B) shall
be applied: [Table not included. See ED. NOTE.]
(g) When the Department makes
an ELE determination and the child meets all MAGI CHIP or MAGI Child Program nonfinancial
eligibility requirements, the household size determined by the Department is used
to determine eligibility regardless of the family size. The countable income of
the household is determined by the ELA. A child is deemed eligible for MAGI CHIP
or MAGI Child Program as follows:
(A) Effective March 1, 2015,
if the MAGI-based income of the household group is below 163 percent of the 2015
federal poverty level as listed below, the Department deems the child eligible for
the MAGI Child Program; [Table not included. See ED. NOTE.]
(B) If the MAGI-based income
of the household group is at or above 163 percent of the FPL through 300 percent
of the FPL as listed in section (4) (f) of this rule, the Agency deems the child
eligible for MAGI CHIP.
[ED. NOTE: Tables referenced are available
from the agency.]
Stat. Auth.: ORS 411.402,
411.404 & 413.042
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 414.025, 414.231, 414.447
& 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 25-2014(Temp), f. &
cert. ef. 4-14-14 thru 10-11-14; DMAP 53-2014, f. & cert. ef. 9-23-14; DMAP
67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. &
cert. ef. 1-30-15; DMAP 6-2015(Temp), f. 2-13-15, cert. ef. 3-1-15 thru 8-27-15;
DMAP 27-2015, f. 4-21-15, cert. ef. 4-22-15
410-200-0400
Specific Requirements; Breast and Cervical
Cancer Treatment Program (BCCTP)
This rule establishes eligibility criteria
for medical assistance based on an individual's need of treatment for breast or
cervical cancer, including pre-cancerous conditions (treatment). The Authority administers
the Oregon Breast and Cervical Cancer Treatment Program (BCCTP) by entering into
agreements with qualified entities as approved by the Authority to provide screening
services for BCCTP funded by the Centers for Disease Control in support of the National
Breast and Cervical Cancer Early Detection Program.
(1) To be eligible for BCCTP,
an individual must:
(a) Be found to need treatment
following screening services provided by a qualified entity;
(b) Be under the age of 65;
(c) Not be covered for treatment
by minimum essential coverage; and
(d) Not be eligible for Medicaid
through a Medicaid program listed in 42 U.S.C. §1396a (a) (10) (A) (i) (mandatory
Medicaid eligibility groups).
(2) An individual is presumptively
eligible for BCCTP beginning the day a qualified entity determines on the basis
of preliminary information that she is likely to meet the requirements of section
(1). A qualified entity that determines an individual presumptively eligible for
BCCTP shall:
(a) Notify the Authority
of the determination within five working days; and
(b) Explain to the individual
at the time the determination is made the circumstances under which an application
for medical assistance shall be submitted to the Authority and the deadline for
the application (see section (3)).
(3) To remain eligible for
benefits, an individual determined by a qualified entity to be presumptively eligible
for BCCTP shall apply for medical assistance no later than the last day of the month
following the month in which the determination of presumptive eligibility is made.
Presumptive eligibility for BCCTP ends on:
(a) The last day of the month
following the month in which presumptive eligibility begins, if the individual does
not file an application by that date;
(b) The day on which a determination
is made for other Medicaid/CHIP program benefits.
(4) An individual found eligible
for the BCCTP by the Authority becomes ineligible upon the first of the following
to occur:
(a) The treating health professional
determines the course of treatment is complete;
(b) Upon reaching age 65;
(c) When the individual becomes
covered for treatment by minimum essential coverage;
(d) Upon becoming a resident
of another state;
(e) When the Authority determines
she does not meet the requirements for eligibility.
Stat. Auth.: ORS 411.402, 411.404, 413.042
& 414.534
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231,
411.447, 414.534, 414.536, 414.540 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; ; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0405
Specific Requirements; Substitute Care
In addition to eligibility requirements
applicable to the Substitute Care program in other rules in chapter 410 division
200, this rule describes specific eligibility requirements for the Substitute Care
program, effective 10/01/13.
(1) To be eligible for Substitute
Care, an individual shall be under the age of 21 and live in an intermediate psychiatric
care facility for which a public agency of Oregon is assuming at least partial financial
responsibility, including those placed in an intermediate psychiatric care facility
by the Oregon Youth Authority.
(2) While living in an intermediate
psychiatric care facility, an individual’s household group consists of the
individual only.
(3) There is no income test
for Substitute Care.
Stat. Auth.: ORS 411.402, 411.404 &
413.042
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 413.032, 413.038, 414.025, 414.231 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0410
Specific Requirements; MAGI CHIP
In addition to eligibility requirements
applicable to the MAGI CHIP program in other rules in chapter 410 division 200,
this rule describes specific eligibility requirements for the MAGI CHIP program.
(1) Individuals may not be
eligible for the MAGI CHIP program with an effective date prior to October 1, 2013.
(2) To be eligible for the
MAGI CHIP program, an individual must be under 19 years of age and must:
(a) Not be eligible for MAGI
Child, MAGI Pregnant Woman, MAGI Parent or Caretaker Relative, or Substitute Care
programs;
(b) Meet budgeting requirements
of OAR 410-200-0315; and
(c) Except as described in
section (4), not be covered by minimum essential coverage. For the purposes of this
rule, a child is not considered to have minimum essential coverage if it is not
accessible for one or more of the following reasons:
(A) The travel time or distance
to available providers within the minimum essential coverage network exceeds:
(i) In urban areas: 30 miles,
30 minutes, or the community standard, whichever is greater; or
(ii) In rural areas: 60 miles,
60 minutes, or the community standard, whichever is greater;
(B) Accessing the minimum
essential coverage would place a household group member at risk of harm.
(3) For the Authority to
enroll a child in MAGI CHIP based on a determination made by an Express Lane Agency
(ELA), the child’s parent or guardian shall give consent in writing, by telephone,
orally, or through electronic signature.
(4) For renewals in 2014,
children with minimum essential coverage shall be enrolled in MAGI CHIP for a full
12-month eligibility period if:
(a) At the time of renewal,
the child is receiving Medicaid based on a 2013 non-MAGI based eligibility determination;
(b) The child meets all other
MAGI CHIP financial and non-financial eligibility requirements, except they are
receiving minimum essential coverage; and
(c) The child loses eligibility
for Medicaid due to MAGI-based eligibility policy effective October 1, 2013, which
eliminated the 50 percent self-employment income disregard.
Stat. Auth.: ORS 411.402, 411.404 &
413.042
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 413.032, 413.038, 414.025, 414.231 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0415
Specific Requirements; MAGI Child
In addition to eligibility requirements
applicable to the MAGI Child program in other rules in chapter 410 division 200,
this rule describes specific eligibility requirements for the MAGI Child program.
(1) Individuals may not be
eligible for the MAGI Child program with an effective date prior to January 1, 2014.
(2) To be eligible for the
MAGI Child program, the child must be under the age of 19 with household income
at or below:
(a) 133 percent of the federal
poverty level (OAR 410-200-0315) for the applicable family size for a child over
the age of one but less than age 19; or
(b) 185 percent of the federal
poverty level for the applicable family size for an infant under the age of one.
(3) To be eligible for the
MAGI Child Program, an individual may not:
(a) Be receiving or deemed
to be receiving SSI benefits;
(b) Be receiving Medicaid
through another program.
(4) A child born to a mother
eligible for and receiving Medicaid benefits is assumed eligible for medical benefits
under this rule until the end of the month the child turns one year of age unless:
(a) The child dies;
(b) The child is no longer
a resident of Oregon; or
(c) The child’s representative
requests a termination of the child’s eligibility.
(5) To enroll a child in
the MAGI Child program based on a determination made by an Express Lane Agency (ELA),
the child's parent or guardian shall give consent in writing, by telephone, orally,
or through electronic signature.
(6) ELE qualifies a child
for medical assistance benefits based on a finding from the Department, even when
the Department’s eligibility methodology differs from that used for OCCS medical
programs.
Stat. Auth.: ORS 411.402, 411.404 &
413.042
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231,
411.447 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0420
Specific Requirements; MAGI Parent or Other
Caretaker Relative
In addition to eligibility requirements
applicable to the MAGI Parent and Other Caretaker Relative program in other rules
in chapter 410 division 200, this rule describes specific eligibility requirements
for the MAGI Parent or Other Caretaker Relative program.
(1) Individuals may not be
eligible for the MAGI Parent and Other Caretaker Relative program with an effective
date prior to January 1, 2014.
(2) To be eligible for the
MAGI Parent or Other Caretaker Relative program, an individual must have household
group income at or below income standard for the applicable family size as identified
in OAR 410-200-0315.
(3) To be eligible for the
MAGI Parent or Other Caretaker Relative program, an individual must have a dependent
child in the home. However, a dependent child for who foster care payments are made
for more than 30 days is not eligible while the payments are being made for the
dependent child.
Stat. Auth.: ORS 411.402, 411.404 &
413.042
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 414.025, 414.231, 411.447
& 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0425
Specific Requirements; MAGI Pregnant Woman
In addition to eligibility requirements
applicable to the MAGI Pregnant Woman program in other rules in chapter 410 division
200, this rule describes specific eligibility requirements for the MAGI Pregnant
Woman program.
(1) Individuals may not be
eligible for the MAGI Pregnant Woman program with an effective date prior to January
1, 2014.
(2) To be eligible for the
MAGI Pregnant Woman program, an individual must be pregnant and:
(a) Have household income
that is at or below 185 percent of the federal poverty level (OAR 410-200-0315);
or
(b) Be eligible for Continuous
Eligibility according to the policy described in OAR 410-200-0135(2).
(3) Once a beneficiary is
eligible and receiving Medicaid through the MAGI Pregnant Woman program, they are
eligible through the end of the calendar month in which the 60th day following the
last day of the pregnancy falls (OAR 410-200-0135).
Stat. Auth.: ORS 411.402, 411.404 &
413.042
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 414.025, 414.231, 411.447
& 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0435
Specific Requirements; MAGI Adult
In addition to eligibility requirements
applicable to the MAGI Adult program in other rules in chapter 410 division 200,
this rule describes specific eligibility requirements for the MAGI Adult program.
(1) An individual may not
be eligible for the MAGI Adult program with an effective date prior to January 1,
2014.
(2) The Agency may not allow
retroactive enrollment into the MAGI Adult program for effective dates prior to
January 1, 2014.
(3) To be eligible for the
MAGI Adult program an individual must:
(a) Be 19 years of age or
older and under age 65; and
(b) Have household income
at or below 133 percent federal poverty level (OAR 410-200-0315) for the applicable
family size.
(4) To be eligible for the
MAGI Adult program, an individual may not be:
(a) Pregnant;
(b) Entitled to or enrolled
for Medicare benefits under part A or B of Title XVIII of the Act;
(c) Receiving SSI benefits;
or
(d) A parent or other caretaker
relative living with a dependent child who is not enrolled in minimum essential
coverage.
Stat. Auth.: ORS 411.402, 411.404 &
413.042
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231,
411.447 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0440
Specific Requirements; Extended Medical
Assistance
(1) The following individuals may be
eligible for Extended Medical Assistance (EXT) if they lose eligibility for Medical
Assistance Assumed (MAA), Medical Assistance to Families (MAF), or MAGI Parent or
Other Caretaker Relative (MAGI PCR) benefits:
(a) Individuals who lose
eligibility for MAA, MAF, or MAGI PCR due to the receipt or increase of earned income
are eligible for 12 months of EXT if eligibility is redetermined and the individual
is not eligible for any other Medicaid/CHIP program.
(b) Individuals who lose
eligibility for MAA, MAF, or MAGI PCR due to the receipt or increase of spousal
support are eligible for four months of EXT benefits if:
(A) Individuals were eligible
for and receiving MAA, MAF, or MAGI PCR benefits for any three of the six months
preceding the receipt or increase in spousal support that resulted in loss of eligibility,
and;
(B) Eligibility is redetermined
and the individual is not eligible for any other Medicaid/CHIP program.
(2) The EXT beneficiary must
be a resident of Oregon.
(3) Individuals who lose
EXT eligibility for one of the following reasons may regain EXT eligibility for
the remainder of the original eligibility period if the requirements outlined in
sections (1) and (2) are met:
(a) EXT eligibility is lost
because the individual leaves the household during the EXT eligibility period. The
individual may regain EXT eligibility if they return to the household; or
(b) EXT eligibility is lost
due to a change in circumstance that results in eligibility for another OCCS medical
program, and then a subsequent change in circumstance occurs that results in ineligibility
for all OCCS medical programs, the individual may regain EXT eligibility.
(4) The effective date of
EXT is the first of the month following the month in which MAA, MAF, or MAGI PCR
program eligibility ends.
(5) If an individual receives
MAA, MAF, or MAGI PCR benefits during months when they were eligible for EXT:
(a) Such months are not an
overpayment;
(b) Any month in which an
individual receives MAA, MAF, or MAGI PCR benefits when they were eligible for EXT
is counted as a month of the EXT eligibility period.
(6) If a beneficiary of MAA,
MAF, or MAGI PCR benefits experiences another change in conjunction with the receipt
or increase of earned income or spousal support, and the other change, by itself,
makes the beneficiary ineligible for the current program, the beneficiary is not
eligible for EXT.
Stat. Auth.: ORS 411.095, 411.402, 411.404,
413.038, 414.025
Stats. Implemented: ORS 411.095,
411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025,
414.231, 411.447, 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14: DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15; DMAP 19-2015(Temp),
f. & cert. ef. 4-2-15 thru 9-28-15; DMAP 31-2015(Temp), f. & cert. ef 6-16-15
thru 9-28-15; DMAP 53-2015, f. 9-22-15, cert. ef. 9-25-15
410-200-0500
Transitioning Benefits — 2013 Programs
(1) For individuals who apply for OCCS
medical programs on or after October 1, 2013, eligibility and budgeting shall be
determined according to this section of rules.
(2) Individuals who apply
from October 1, 2013 through December 31, 2013 shall first be considered for the
programs described in OAR 410-200-0510. If an individual is eligible for one of
those programs, eligibility shall continue according to section (3) of this rule.
Individuals found ineligible based on information from all budget months of October,
November, or December 2013 shall have their eligibility determined as follows:
(a) Individuals who would
be eligible for new programs based on eligibility and income standards that begin
January 1, 2014, shall become eligible for applicable programs as of that date;
(b) Individuals who are ineligible
for new programs that begin on January 1, 2014 shall be referred to the Exchange.
(3) Individuals who are eligible
and receiving OCCS medical program benefits described in OAR 410-200-0510 on December
31, 2013, shall be treated as follows effective January 1, 2014:
(a) Individuals receiving
OHP-OPU program benefits shall be converted to the MAGI Adult program;
(b) Individuals receiving
HKC program benefits shall be converted to the MAGI CHIP program;
(c) Individuals receiving
OHP-CHP whose household income is below 133 percent of FPL shall be converted to
the MAGI Child program;
(d) All others shall maintain
their current program benefits until:
(A) A change occurs that
impacts their eligibility; or
(B) Their next scheduled
renewal occurs according to OAR 410-200-0115.
Stat. Auth.: ORS 411.402, 411.404 &
413.042
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 414.025, 414.231, 411.447
& 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0505
Specific Requirements; Fast Track Eligibility
and Enrollment for MAGI Medicaid
For Fast Track eligibility and enrollment,
the Authority provides MAGI Medicaid benefits based on an individual’s eligibility
for SNAP program benefits, or for individuals who are parents of children determined
eligible for OCCS Medicaid programs.
(1) A SNAP recipient adult
may be found eligible for Fast Track eligibility and enrollment based on findings
from the Department, even if the Department’s eligibility methodology differs
from that used by the Authority OCCS medical program if the adult:
(a) Has SNAP income is at
or below the applicable income standards for MAGI Adult;
(b) Indicates they wish to
pursue medical assistance;
(c) Is not eligible for or
receiving Supplemental Security Income;
(d) Agrees to cooperate with
the Division of Child Support; and
(e) Meets the specific program
requirements for MAGI Adult.
(2) The adult parent or parents
of a MAGI Medicaid eligible child may be found eligible for Fast Track eligibility
and enrollment if the adult:
(a) Indicates they wish to
pursue medical assistance;
(b) Is not eligible for or
receiving Supplemental Security Income;
(c) Agrees to cooperate with
the Division of Child Support; and
(d) Meets the specific program
requirements for the applicable program.
(3) A new application is
not required for Fast Track eligibility and enrollment.
(4) If the individual requests
Fast Track eligibility and enrollment and is not eligible due to eligibility for
or receipt of Supplemental Security Income, the Authority shall refer the applicant
to Aging and People with Disabilities for an eligibility determination. The Date
of Request is the date the Authority received consent for Fast Track eligibility
and enrollment.
Stat. Auth.: ORS 411.402, 411.404, 413.042
& 413.038
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 413.032, 413.038, 414.025, 414.231 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15
410-200-0510
Specific Program Requirements; BCCM, CEC,
CEM, EXT, MAA, MAF, OHP, and Substitute Care
(1) This rule describes OCCS medical
programs for which individuals may be determined eligible through December 31, 2013.
See OAR 410-200-0500 for information regarding the treatment of those beneficiaries
as of January 1, 2014.
(2) To be eligible for a
program listed in this rule, an individual must meet the following:
(a) The eligibility factors
set forth in OAR 410-200-0200 through 410-200-0240;
(b) The budgeting and income
standard requirements set forth in OAR 410-200-0300 through 410-200-0315; and
(c) The individual must have
established a Date of Request prior to January 1, 2014.
(3) For purposes of this
rule, private major medical health insurance means a comprehensive major medical
insurance plan that, at a minimum, provides physician services; inpatient and outpatient
hospitalization; outpatient lab, x-ray, immunizations; and prescription drug coverage.
This term does not include coverage under the Kaiser Child Health Program or Kaiser
Transition Program but does include policies that are purchased privately or are
employer-sponsored.
(4) For the purposes of this
rule, the receipt of private major medical health insurance does not affect OCCS
medical program eligibility if it is not accessible. Private major medical health
insurance is not considered accessible if:
(a) The travel time or distance
to available providers exceeds:
(A) In urban areas: 30 miles,
30 minutes, or the community standard, whichever is greater;
(B) In rural areas: 60 miles,
60 minutes, or the community standard, whichever is greater;
(b) Accessing the private
major medical health insurance would place a filing group member at risk of harm.
(5) To be eligible for Chafee
medical, the individual must be a child who was receiving foster care in Oregon
upon attaining:
(a) Age 18; or
(b) If over 18, the age at
which Oregon Medicaid or Oregon Tribal foster care assistance ended under Title
IV-E of the Act;
(6) CEM provides eligibility
for the balance of the 12-month eligibility period for non-CAWEM children who were
receiving Child Welfare (CW) medical, EXT, MAA, MAF, OHP, OSIPM, or Substitute Care
program benefits and lost eligibility for reasons other than moving out of state
or turning 19 years old. CEM benefits end when:
(a) The child becomes eligible
for CW medical, EXT, MAA, MAF, OHP, OSIPM, or Substitute Care program benefits;
(b) The child turns 19 years
of age;
(c) The child moves out of
state; or
(d) Benefits are closed voluntarily.
(7) CEC provides eligibility
for the OHP-CHP program for non-CAWEM pregnant children who were receiving OHP-CHP
and would have otherwise lost eligibility for reasons other than moving out of state
or becoming a recipient of private major medical health insurance. CEC eligibility
for OHP-CHP ends the day following the end of the month in which the earliest of
the following occur:
(a) The pregnancy ends;
(b) The individual moves
out of state;
(c) The individual begins
receiving private major medical health insurance;
(d) Benefits are closed voluntarily;
or
(e) The individual becomes
eligible for CW medical, EXT, MAA, MAF, OHP, OSIPM, or Substitute Care program benefits.
(8) For the Authority to
enroll a child in the program based on a determination made by an ELA, the child's
parent or guardian shall give consent in writing, by telephone, orally, or through
electronic signature.
(9) To be eligible for EXT,
an individual must have been eligible for and receiving MAA or MAF and became ineligible
due to a caretaker relative’s increased earned income or due to increased
spousal support (OAR 410-200-0440).
(10) To be eligible for MAA
or MAF, an individual must be one of the following:
(a) A dependent child who
lives with a caretaker relative. However, a dependent child for whom foster care
payments are made for more than 30 days is not eligible while the payments are being
made;
(b) A caretaker relative
of an eligible dependent child. However, a caretaker relative to whom foster care
payments are made for more than 30 days is not eligible while the payments are being
made;
(c) A caretaker relative
of a dependent child, when the dependent child is ineligible for MAA or MAF for
one of the following reasons:
(A) The child is receiving
SSI;
(B) The child is in foster
care but is expected to return home within 30 days; or
(C) The child’s citizenship
has not been documented;
(d) An essential person.
An essential person is a member of the household group who:
(A) Is not required to be
in the filing group;
(B) Provides a service necessary
to the health or protection of a member of the household group who has a mental
or physical disability; and
(C) Is less expensive to
include in the benefit group than the cost of purchasing this service from another
source;
(e) A parent of an unborn
as follows:
(A) For the MAA program:
(i) Any parent whose only
child is an unborn child, once the mother’s pregnancy has reached the calendar
month preceding the month in which the due date falls;
(ii) The father of an unborn
child who does not meet the criteria described in subsection (e)(A)(i) of this part
may be eligible if there is another dependent child in the household group;
(B) For the MAF program,
a mother whose only child is an unborn child, once the mother’s pregnancy
has reached the calendar month preceding the month in which the due date falls.
(11) To be eligible for any
OHP program in sections (12) through (15), an individual may not be:
(a) Receiving SSI benefits;
(b) Eligible for Medicare,
except that this requirement does not apply to the OHP-OPP program;
(c) Receiving Medicaid through
any other program concurrently.
(12) To be eligible for the
OHP-OPC program, an individual must be less than 19 years of age.
(13) To be eligible for the
OHP-OP6 program, a child must be less than six years of age and not eligible for
OHP-OPC.
(14) To be eligible for the
OHP-OPP program, an individual must:
(a) Be pregnant;
(b) Be within the time period
through the end of the calendar month in which the 60th day following the last day
of the pregnancy falls; or
(c) Be an infant under age
one.
(15) To be eligible for the
OHP-CHP program, an individual must be under 19 years of age and must:
(a) Not be eligible for the
OHP-OPC, OHP-OPP, or OHP-OP6 programs; and
(b) Not be covered by any
private major medical health insurance. An individual may be eligible for OHP-CHP
if the private major medical health insurance is not accessible as outlined in section
(4).
(16) Effective July 1, 2004,
the OHP-OPU program is closed to new applicants. Except as provided in subsections
(a) and (b) of this section, a new applicant may not be found eligible for the OHP-OPU
program:
(a) An individual is not
a new applicant if the Department determines that the individual is continuously
eligible for medical assistance as follows:
(A) The individual is eligible
for and receiving benefits under the OHP-OPU program on June 30, 2004, and the Department
determines that the individual continues after that date to meet the eligibility
requirements for the OHP-OPU program;
(B) The individual is eligible
for and receiving benefits under the CAWEM program on June 30, 2004 and is eligible
for the CAWEM program based on the OHP-OPU program, and the Department determines
that the individual continues to meet the eligibility requirements for the OHP-OPU
program except for citizenship or alien status requirements;
(C) The eligibility of the
individual ends under the BCCM, CEC, CEM, EXT, GAM, HKC, MAA, MAF, OHP-CHP, OHP-OPC,
OHP-OPP, OSIPM, REFM, or Substitute Care program, or the related CAWEM program;
or because the individual has left the custody of the Oregon Youth Authority (OYA);
and at that time the Department determines that the individual meets the eligibility
requirements for the OHP-OPU program;
(D) The individual is a child
in the custody of the Department whose eligibility for Medicaid ends because of
the child's age and at that time the Department determines that the individual meets
the eligibility requirements for the OHP-OPU program;
(E) The Department determines
that the individual was continuously eligible for the OHP-OPU program on or after
June 30, 2004 under paragraphs (A) to (D) of this section;
(b) An individual who is
not continuously eligible under subsection (a) is not a new applicant if the individual:
(A) Has eligibility end under
the BCCM, CEC, CEM, EXT, HKC, MAA, MAF, OHP-CHP, OHP-OPP, OHP-OPU, OSIPM, REFM,
or Substitute Care program, or the related CAWEM program; because the individual
has left the custody of the OYA; or is a child in the custody of the Department
whose eligibility for Medicaid ends due to the child's age;
(B) Established a Date of
Request prior to the eligibility ending date in paragraph (A) of this section; and
(C) Meets the eligibility
requirements for the OHP-OPU program or the related CAWEM program within either
the month of the Date of Request or, if ineligible in the month of the Date of Request,
the following month.
(17) To be eligible for the
OHP-OPU program, an individual must meet the requirements listed in section (16)
and be 19 years of age or older and may not be pregnant. Additionally, and individual
must meet the following requirements:
(a) Must be currently receiving
Medicaid or CHIP benefits when determined eligible for OHP- OPU;
(b) Must not be covered by
any private major medical health insurance. An individual may be eligible for OHP-CHP
if the private major medical health insurance is not accessible as outlined in section
(4);
(c) May not have been covered
by private major medical health insurance during the six months preceding the effective
date for starting medical benefits. The six-month waiting period is waived if:
(A) Any of the criteria in
section (4) are met;
(B) The individual has a
condition that, without treatment, would be life-threatening or would cause permanent
loss of function or disability;
(C) The individual’s
health insurance premium was reimbursed because the individual was receiving Medicaid,
and the Department or the Authority found the premium was cost-effective;
(D) The individual’s
health insurance was subsidized through FHIAP or the Office of Private Health Partnerships
in accordance with ORS 414.231, 414.826, 414.831, and 414.839; or
(E) A member of the individual’s
household group was a victim of domestic violence.
(18) To be eligible for the
Substitute Care program, an individual must meet the specific eligibility requirements
for Substitute Care found in OAR 410-200-0405.
(19) Except for OHP-CHP and
CEC, a pregnant woman who is eligible for and receiving benefits through any program
listed in this rule remains eligible through the end of the calendar month in which
the 60th day following the last day of the pregnancy falls.
(20) A child who becomes
ineligible for the OHP program because of age while receiving in-patient medical
services remains eligible until the end of the month in which he or she no longer
receives those services if he or she is receiving in-patient medical services on
the last day of the month in which the age requirement is no longer met.
Stat. Auth.: ORS 411.402, 411.404, ,
413.042 & 414.534
Stats. Implemented: ORS 411.400,
411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231,
411.447, 414.534, 414.536 & 414.706
Hist.: DMAP 54-2013(Temp),
f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14
thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14,
cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1-30-15


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