Or. Admin. R. 461-135-0010 - Assumed and Continuous Eligibility for Medical Programs
(1) This rule sets out when an individual is
assumed eligible for certain medical programs because the individual receives
or is deemed to receive benefits of another program. This rule also sets out
when the eligibility (see OAR 461-001-0000) of an individual
shall continue after they become ineligible.
(2) A pregnant individual who is eligible for
and receiving benefits the day the pregnancy ends is continuously eligible for
the OSIPM program until the last day of the twelfth month following the month
in which the last day of the pregnancy falls.
(3) A pregnant individual who was eligible
for and receiving medical assistance under the OSIPM program and becomes
ineligible while pregnant is continuously eligible for Medicaid and can
continue to receive OSIPM benefits until the last day of the twelfth month
following the month in which the last day of the pregnancy falls.
(4) A child (see OAR
461-001-0000) born to an individual eligible for and receiving OSIPM benefits
is assumed eligible for medical benefits under this section until the end of
the month the child turns one year of age.
(5) The individuals described in subsection
(a) and (b) of this section are assumed eligible for OSIPM (except OSIPM-EPD)
unless subsection (c) or (d) of this section applies:
(a) A recipient of Supplemental Security
Income (SSI) benefits who meets all non-financial requirements for the OSIPM
program except citizen and noncitizen status. SSI recipients are presumed to
meet all citizen and noncitizen status requirements for the OSIP
program.
(b) An individual who
meets all non-financial requirements for the OSIPM program except citizen and
noncitizen status and is 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.
Individuals deemed eligible for SSI under Sections 1619(a) or (b) of the Social
Security Act are assumed to meet all citizen and noncitizen status requirements
for the OSIPM program.
(c) An
individual described in subsection (a) or (b) of this section who is in a
nonstandard living arrangement (see OAR 461-001-0000) is not
eligible for long-term care (see OAR 461-001-0000) services if
the individual would otherwise be ineligible for OSIPM due to a disqualifying
transfer of assets (OAR 461-140-0210 to 461-140-0300 regulate the effect of a
transfer of assets on a client).
(d) An individual described in subsection (a)
or (b) of the section who is in a nonstandard living
arrangement is not assumed eligible for long-term care services if
countable (see OAR 461-001-0000) resources exceed the limit
after performing the calculation under OAR 461-160-0580.
(6) For the purposes of this section the
definition of a "child" means an unmarried individual under age 19 and includes
natural, step, and adoptive children. When eligibility for a
child is redetermined and would result in a loss of
eligibility for OSIPM prior to the end of the renewal month,
the child remains continuously eligible for OSIPM through the end of the
renewal month, unless the child:
(a) No longer
meets the definition of a child given in this section;
(b) Moves out of state;
(c) Voluntarily ends benefits; or
(d) Is eligible for any other medical program
that provides OHP Plus benefits.
(7) An individual who receives both benefits
under Part A of Medicare and SSI benefits is assumed eligible for the QMB-BAS
program unless the individual does not meet the requirements of OAR
461-120-0345 or the residency requirements (see OAR 461-120-0010).
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 409.010, 411.060, 411.070, 411.404 & 42 CFR 435.926
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(1) This rule sets out when an individual is assumed eligible for certain medical programs because the individual receives or is deemed to receive benefits of another program.
(2) A pregnant individual who is eligible for and receiving benefits the day the pregnancy ends is assumed eligible for the OSIPM program until the last day of the twelfth month following the month in which the last day of the pregnancy falls.
(3) A pregnant individual who was eligible for and receiving medical assistance under the OSIPM program or HSD medical programs(see OAR 461-001-0000) and becomes ineligible while pregnant is assumed eligible for Medicaid and can continue to receive OSIPM or HSD medical programs benefits until the last day of the twelfth month following the month in which the last day of the pregnancy falls.
(4) A child (see OAR 461-001-0000) born to an individual eligible for and receiving OSIPM benefits is assumed eligible for medical benefits under this section until the end of the month the child turns one year of age.
(5) The individuals described in subsection (a) and (b) of this section are assumed eligible for OSIPM (except OSIPM-EPD) unless subsection (c) or (d) of this section applies:
(a) A recipient of Supplemental Security Income (SSI) benefits who meets all non-financial requirements for the OSIPM program except citizen and noncitizen status. SSI recipients are presumed to meet all citizen and noncitizen status requirements for the OSIP program .
(b) An individual who meets all non-financial requirements for the OSIPM program except citizen and noncitizen status and is 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. Individuals deemed eligible for SSI under Sections 1619(a) or (b) of the Social Security Act are assumed to meet all citizen and noncitizen status requirements for the OSIPM program.
(c) An individual described in subsection (a) or (b) of this section who is in a nonstandard living arrangement (see OAR 461-001-0000) is not eligible for long-term care (see OAR 461-001-0000) services if the individual would otherwise be ineligible for OSIPM due to a disqualifying transfer of assets (OAR 461-140-0210 to 461-140-0300 regulate the effect of a transfer of assets on a client).
(d) An individual described in subsection (a) or (b) of the section who is in a nonstandard living arrangement is not assumed eligible for long-term care services if countable (see OAR 461-001-0000) resources exceed the limit after performing the calculation under OAR 461-160-0580.
(6) For the purposes of this section the definition of a "child" means an unmarried individual under age 19 and includes natural, step, and adoptive children. A child found eligible for OSIPM is assumed eligible until the end of the twelfth month following the determination of the child's OSIPM eligibility or redetermination of eligibility unless the child:
(a) No longer meets the definition of a child given in this section;
(b) Moves out of state;
(c) Voluntarily ends benefits; or
(d) Is eligible for any other Medicaid program that provides OHP Plus benefits.
(7) An individual who receives both benefits under Part A of Medicare and SSI benefits is assumed eligible for the QMB-BAS program unless the individual does not meet the requirements of OAR 461-120-0345 or the residency requirements (see OAR 461-120-0010).
Notes
Statutory/Other Authority: ORS 409.050, ORS 411.060, 411.070, 411.404, 413.085 & 414.685
Statutes/Other Implemented: ORS 409.010, 411.060, 411.070 & 411.404