Or. Admin. R. 461-135-0010 - Assumed, Continuous, and Protected Eligibility; OSIPM, QMB
(1) This rule sets
out when medical program eligibility (see OAR
461-001-0000) of an individual
is assumed, continuous, or protected. An individual may be granted any
combination of assumed, continuous, or protected eligibility at the same
time.
(2) Assumed eligibility.
Assumed eligibility means an individual is assumed eligible for certain medical
programs because the individual receives or is deemed to receive benefits of
another program.
(a) An individual described
in paragraphs (A) or (B) of this subsection who meets the residency
requirements in OAR 461-120-0010, the requirements
in section (1) of OAR
461-120-0345, and the medical
assignment requirements in OAR
461-120-0315, is assumed
eligible for OSIPM.
(A) A recipient of
Supplemental Security Income (SSI) benefits.
(B) An individual deemed eligible for SSI
under Sections 1619(a) or (b) of the Social Security Act (42 U.S.C. 1382h(a) or
(b), which cover individuals with
disabilities whose impairments have not changed but who have become gainfully
employed and have continuing need for OSIPM.
(b) An individual who receives benefits under
both Part A of Medicare and SSI is assumed eligible for the QMB-BAS program
unless the individual does not meet the residency requirements in OAR
461-120-0010, the requirements
in section (1) of OAR
461-120-0345, and the medical
assignment requirements in OAR
461-120-0315.
(3) Continuous eligibility. The
provisions in this section are effective July 1, 2023. Continuous eligibility
(CE) means a period during which medical benefits are not reduced or closed,
except for as provided in paragraphs (c)(F) and (c)(G) of this section. The
period during which medical benefits are not reduced or closed is called a CE
period. Eligibility for a CE period and exceptions to CE are
covered in this section.
(a) Children under 6
years are granted a CE period beginning the first day of the month of the
medical benefit effective date (see OARs
461-180-0090,
461-180-0100, and
461-180-0085) and ending on the
last day of the month the child turns 6 years or 24 months from the CE period
beginning date, whichever is later, when one of the following is met:
(A) Medical benefits with a date of
request (see OAR
461-115-0030) of July 1, 2023,
or later are approved for an initial month, a renewal, or a
redetermination; and there is no outstanding request for information.
(B) Medical benefits with a date of
request of April 1, 2023, or later were approved for an
initial month, a renewal, or a redetermination; there is no
outstanding request for information; and the medical benefits are ongoing on
July 1, 2023.
(b)
Individuals 6 years or older are granted a 24-month CE period beginning the
first day of the month of the medical benefit effective date (see OARs
461-180-0090,
461-180-0100, and
461-180-0085) when one of the
following is met:
(A) Medical benefits with a
date of request of July 1, 2023, or later are approved for an
initial month, a renewal, or a redetermination; and there is
no outstanding request for information.
(B) Medical benefits with a date of
request of April 1, 2023, or later were approved for an
initial month, a renewal, or a redetermination; there is no
outstanding request for information; and the medical benefits are ongoing on
July 1, 2023.
(c) CE
special situations and exceptions. Notwithstanding other provisions of this
rule section --
(A) Prior to July 1, 2023,
there is no CE for QMB programs.
(B) There is no CE for individuals receiving
OSIPM-Acute Care (see OARs
461-101-0010 and
461-135-0745) or OSIPM under OAR
461-135-0750.
(C) Prior to April 1, 2023, in the OSIPM
program, individuals 18 years or younger are eligible for a CE period as
provided under previous OAR
461-135-0010 on the date medical
program eligibility was determined.
(D) For individuals 19 years or older:
(i) There is no CE for medical
eligibility determined from a date of request
(see OAR 461-115-0030) before April 1,
2023.
(ii) There is no CE when
medical benefit redetermination or renewal -
(I) Is based on a date of
request on or after April 1, 2023; and
(II) Results in a medical benefit approval,
but the approval is only to allow the individual the required 60-day advance
notice of closure or reduction required under OAR
461-135-0880.
(iii) There is no CE for medical
benefits restored solely due to the October 11, 2023, Oregon Eligibility
Partnership transmittal OEP-AR-23-054 as the administrative restoration was not
a result of a determination of financial and non-financial medical program
eligibility.
(E) When an individual is eligible for
retroactive medical benefits (see OAR
461-180-0140), the CE period
does not begin on the date of retroactive eligibility. For
example, if an applicant with a November 28 date of request is
eligible for initial month benefits, as well as retroactive
medical for the month of September, the CE period begin date is November
1.
(F) When an individual becomes a
resident of a public institution (see OAR
461-135-0950), the Department
shall suspend medical benefits as required under rule, and the CE period
remains unchanged.
(G) When any of
subparagraphs (i) through (v) occur, medical benefits shall be closed as
required under rule and the CE period is lost. The CE period may only be
restored under paragraph (H) of this subsection.
(i) The individual is no longer an Oregon
resident.
(ii) The death of the
individual.
(iii) The individual or
someone authorized to act on their behalf voluntarily closes medical
benefits.
(iv) Benefits were
approved in error at the most recent determination or renewal of
eligibility because of administrative error, or because of
fraud, abuse, or perjury attributed to the individual or someone authorized to
act on their behalf.
(v) In the QMB
programs, the individual becomes disenrolled in Medicare Part A.
(H) The CE period is restored when
all of the following happen:
(i) The reason
the individual's CE ended no longer exists.
(ii) The individual establishes a
date of request for medical benefits on or before the last day
of the month following the month the medical program closed.
(iii) The individual is not eligible for
medical benefits based on the new application.
(d) Department administration of CE. In the
OSIPM programs, the Department may change the medical program of the individual
as long as the benefit package is not reduced.
(A) When an individual no longer meets the
OSIPM program financial requirements, but still meets non-financial
requirements, the individual shall be eligible for the OSIPM program with the
uppermost income limit for which they meet non-financial
requirements.
(B) When both of the
following are true, an individual shall receive medical benefits through the
Parent or Caretaker Relative program (see OAR
410-200-0420):
(i) The individual no longer meet the OSIPM
basis of need (see OAR
461-120-0310), and
(ii) The individual does not meet the
non-financial eligibility requirements for HSD Medical
Programs of the same or better benefit.
(4) Protected eligibility.
Protected eligibility means an individual determined eligible for an Oregon
Health Plan (OHP) Plus benefit shall have that eligibility
protected, despite changes in circumstance that would otherwise close or reduce
benefits. Protected eligibility and exceptions to protected eligibility are
covered in this section.
(a) In the OSIPM
programs, an individual who is eligible for and receiving OSIPM for any portion
of their pregnancy is entitled to protected eligibility for the duration of the
pregnancy and the postpartum eligibility period.
(b) The postpartum
eligibility period is 12 calendar months following the month
in which the pregnancy ends.
(c)
Benefits may not be closed or reduced during a period of protected eligibility
unless one of the following occurs:
(A) The
individual is no longer an Oregon resident.
(B) The death of the individual.
(C) The individual or someone authorized to
act on their behalf voluntarily closes medical benefits.
(D) Benefits were approved in error at the
most recent determination or renewal of eligibility because of
administrative error, or because of fraud, abuse, or perjury attributed to the
individual or someone authorized to act on their behalf.
Notes
Statutory/Other Authority: ORS 409.050, ORS 411.060, 411.070, 411.404, 413.085, 414.685 & 42 CFR 435.926
Statutes/Other Implemented: ORS
411.060,
411.070,
411.404, ORS
409.010,
42 CFR
435.926,
42 CFR
435.120,
42 CFR
435.123,
42 CFR
435.170, American Rescue Plan Act of 2021
(PL
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