Or. Admin. Code § 410-200-0015 - General Definitions
(1) "Action" means
a termination, suspension, denial, or reduction of Medicaid or CHIP eligibility
or covered services.
(2) "Active
renewal" means the renewal process for cases that are not processed via
automated renewal wherein a prepopulated renewal notice is sent to the head of
household and authorized representative, if applicable. The active renewal
notice is populated with the most current case information relevant to
renewal.
(3) "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.
(4) "AEN" means Assumed
Eligible Newborn (OAR
410-200-0115).
(5) "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 of 2011 (Pub. L.
112-56 ).
(6) "Agency" means the Oregon Health
Authority and Oregon Department of Human Services.
(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 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 at least 18 years of age 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) "Automated renewal" means a renewal of
eligibility, initiated by the Agency, based on reliable information contained
in the beneficiary's case record, using the Federal Data Services Hub and
automated electronic verification sources available to the agency to perform
data matches for the sake of verifying eligibility criteria.
(13) "Beneficiary" means an individual who
has been determined eligible and is currently receiving HSD Medical Program
benefits, Aging and People with Disabilities medical program benefits, or
APTC.
(14) "BRS" means Behavior
Rehabilitation Services.
(15)
"Budget month" means the calendar month from which financial and nonfinancial
information is used to determine eligibility.
(16) "Caretaker" means a parent, caretaker
relative, or non-related caretaker who assumes primary responsibility for a
child's care.
(17) "Caretaker
relative" means an individual with whom the child is living who assumes primary
responsibility for the child's care, and who is one of the following:
(a) A relative of the dependent child, as
follows:
(A) A blood or half-blood relative,
including parents, siblings, first cousins, nephews, nieces, and individuals of
preceding generations as denoted by prefixes of grand, great, or
great-great.
(B) Stepfather,
stepmother, stepbrother, and stepsister.
(C) An individual who legally adopts the
child and any individual related to the individual adopting the
child.
(b) The spouse of
the parent or relative even after the marriage is terminated by death or
divorce;
(18) "CWM"
means Citizenship Waived Medical (CWM) and was a benefit package that ended on
June 30, 2023. The CWM benefit package covered certain emergency services
provided to individuals who met the financial and non-financial eligibility
requirements for an HSD Medical Program, except they did not meet citizenship
and non-citizen status requirements (OAR
410-200-0215). For information
about CWM benefits and eligibility prior to July 1, 2023, see OARs
410-134-0005 and
410-200-0240.
(19) "CWM Plus" means Citizenship Waived
Medical Plus. CWM Plus was a benefit package that was previously referred to as
"CWX" and ended on June 30, 2023. CWM Plus provided OHP Plus benefits to
pregnant individuals and individuals who were sixty (60) days post-partum and
who met the financial and non-financial status requirements for an HSD Medical
Program, excluding MAGI Expanded Adult, except they did not meet the
citizenship and non-citizen status requirements identified in OAR
410-200-0215. For more
information about CWM Plus benefits and eligibility prior to July 1, 2023, see
OARs 410-134-0005 and
410-200-0240.
(20) "Child" means an individual including
minor parent, under the age of 19. Child does not include an unborn.
(21) "Children's Health Insurance Program"
also called "CHIP" means Oregon medical coverage under Title XXI of the Social
Security Act.
(22) "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.
(23) "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.
(24) "Claimant" means an individual who has
requested a hearing or appeal.
(25)
"Code" means Internal Revenue Code.
(26) "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 HSD Medical Programs
for which a determination or denial was made by the Authority.
(27) "Community Partner" has the same meaning
as "Community Partner" as defined in OAR
410-120-0000.
(28) "Coordinated content" means information
included in an eligibility notice regarding the transfer of the individual's or
household's electronic account to another insurance affordability program for a
determination of eligibility.
(29)
"Cover All Kids" refers to the OHP Plus-equivalent benefit (OAR
410-120-1210) provided to
children who meet all eligibility requirements for MAGI Medicaid/CHIP except
for the Citizenship and Non-Citizen Status Requirements (OAR
410-200-0215). As of July 1,
2022, Cover All Kids is included under Healthier Oregon as defined in OAR
410-134-0001.
(30) "Custodial Parent" means, for children
whose parents are divorced, separated, or unmarried, the parent with whom the
child lives, with the following considerations:
(a) If the child lives part-time with both
parents, the parent with whom the child spends most nights is the custodial
parent; or
(b) If section (30)
subsection (a) cannot be determined due to the child spending equal nights with
both parents, a court order or binding custody agreement establishing physical
custody is used to identify the custodial parent.
(31) "Date of Request (DOR)" means the date
on which the applicant or an individual authorized to act on behalf of the
applicant contacts the Authority, the Department, or the FFM to request medical
benefits.
(a) For new applicants, the DOR is
established as follows:
(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.
(b) For current beneficiaries of HSD Medical
Programs, the Date of Request is:
(A) The date
the beneficiary or someone authorized to act on the beneficiary's behalf
reports a change requiring a redetermination of eligibility;
(B) The month an individual ages off a
medical program.
(C) For Automated
Renewals the Date of Request is the date the Agency initiates the Automated
Renewal if there is no RFI generated; or
(D) For Active Renewals, and for Automated
Renewals which result in the generation of an RFI, the Date of Request is the
date on which the Agency receives a response to the Active renewal or
RFI.
(c) The request may
be submitted via the Internet, by telephone, community partner, by mail, by
electronic communication, or in person.
(32) "Decision notice" means a written notice
of a decision made regarding eligibility for an HSD Medical Program benefit. A
decision notice may be a;
(a) "Basic decision
notice" mailed no later than:
(A) The date of
action given in the notice; or
(B)
When suspending benefits due to incarceration (OAR
410-200-0140), the effective
date is the day following the date on which the individual became
incarcerated.
(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 (10) calendar days before the effective date of the change,
except for clients in the Address Confidentiality Program, for whom it shall be
mailed no later than fifteen (15) calendar days before the effective date of
the change.
(33)
"Department" means the Oregon Department of Human Services.
(34) "Dependent child" means an individual
who:
(a) 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 the individual may reasonably be expected to complete the school
or training before attaining age 19.
(b) Lives in the home of the parent or
caretaker relative; and
(c) Is not
absent from the home for more than thirty (30) days due to being in foster care
while foster care payments are being made.
(35) "Express Lane Agency (ELA)" means the
Oregon Department of Human Services making determinations regarding one or more
eligibility requirements for the MAGI Child or MAGI CHIP programs.
(36) "Express Lane Eligibility (ELE)" 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.
(37) "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 documentation and information collected or generated as part of a
fair hearing process conducted by the Authority or the FFM appeals
process.
(38) "Electronic
application" means an application electronically signed and submitted through
the Internet.
(39) "Eligibility
determination" means an approval or denial of eligibility and a renewal or
termination of eligibility.
(40)
"Eligibility Determination Group" (EDG) means all persons whose financial and
non-financial information is considered in determining each medical applicant's
eligibility as defined in OAR
410-200-0305.
(41) "Expedited appeal" also called
"expedited hearing" means a hearing held within five (5) working days of the
Agency's receipt of a hearing request, unless the claimant requests more
time.
(42) "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 EDG and each
unborn child of any pregnant members of the EDG.
(43) "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 the Social Security Administration composite, the Department of
Treasury, and the Department of Homeland Security.
(44) "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).
(45) "Federally Facilitated Marketplace
(FFM)" means the online marketplace operated by the US Department of Health and
Human Services which determines eligibility for Advanced Premium Tax Credit
(APTC) and Cost Sharing Reductions (CSR). The FFM also performs eligibility
assessments for Oregon Medicaid/CHIP and refers to the Agency electronic
accounts of individuals who are found potentially eligible.
(46) "Head of household (HOH)" means the
primary person the Agency shall communicate with and:
(a) Is listed as the case name; or
(b) Is the individual named as the primary
contact on the application.
(47) "Health Systems Division Medical
Programs (HSD Medical Programs)" means all programs under the Health Systems
Division including:
(a) "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;
(b) "Substitute Care" means
medical coverage for children in BRS or PRTF;
(c) "BCCTP" means Breast and Cervical Cancer
Treatment Program;
(d) "FFCYM"
means Former Foster Care Youth Medical;
(e) OHP Bridge - Basic Health
Program
(f) "MAGI Medicaid/CHIP"
means HSD Medical Programs for which eligibility is based on MAGI methodology,
including:
(A) MAGI Child;
(B) MAGI Parent or Caretaker
Relative;
(C) MAGI Pregnant
Woman;
(D) MAGI Children's Health
Insurance Program (CHIP);
(E) MAGI
Adult;
(F) MAGI Expanded
Adult
(G) OHP Bridge -Basic
Medicaid
(48)
"Healthier Oregon" is defined in OAR
410-120-0000.
(49) "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.
(50) "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 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 the
FFM with cost-sharing reductions established under section 1402 of the
Affordable Care Act.
(51) "Legal argument" has the meaning given
that term in OAR 137-003-0008(c).
(52) "Medicaid" means Oregon's Medicaid
program under Title XIX of the Social Security Act.
(53) "MAGI" means Modified Adjusted Gross
Income and is used in determining eligibility based on annual income as
described in OAR 410-200-0310(4).
MAGI 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 section (53)(a), IRC §
6012(a) (1) is used to
determine who is required to file a tax return.
(54) "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) An amount received as a non-recurring
lump sum, if taxable, is counted as income only in the month
received;
(b) Scholarships, awards,
or fellowship grants used for education purposes and not for living expenses
are excluded;
(c) Income from the
following American Indian and Alaska Native sources is excluded:
(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:
(i) Rights of ownership or possession in any
lands described in subsection (c)(B) of this section; or
(ii) 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:
(i)
Located on or near a reservation or within the most recent boundaries of a
prior federal reservation; or
(ii)
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.
(55) "Minimum Essential Coverage
(MEC)" means medical coverage under:
(a) A
government-sponsored plan, including Medicare Part A, Medicaid (excluding CWM),
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) Health
insurance plans in place on or before March 23, 2010; 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.
(56) "Non-applicant" means an individual not
seeking an eligibility determination for themselves and is included in an
applicant's or beneficiary's household to determine eligibility for the
applicant or beneficiary.
(57)
"Non-citizen" means any individual who is not a citizen or national of the
United States as defined at 8
U.S.C.
1101(a)(22).
(58) "OSIPM" means Oregon Supplemental Income
Program Medical. Medical coverage for individuals who are 65 years of age or
older, who are blind, or who have a disability. This program is administered by
the Oregon Department of Human Services.
(59) "Parent" means a natural or biological,
adopted, or stepparent.
(60)
"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.
(61) "Primary Contact" has the same meaning
given "head of household" in this rule.
(62) "PRTF" means Psychiatric Residential
Treatment Facility.
(63) "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);
(C) A publicly operated community residence
that serves no more than sixteen (16) residents, as defined in
42 CFR
435.1009.
(64) "Qualified hospital" means a hospital
that meets all of the following criteria:
(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 to complete a full application by the end
of the presumptive eligibility period and offers applicants assistance with
completing and submitting the full Medicaid application; 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).
(65) "Reasonable opportunity
period";
(a) May be used to obtain necessary
verification or resolve discrepancies regarding an attestation of US
citizenship or non-citizen status (OAR
410-200-0230
(2));
(b) Begins on and shall extend ninety (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 (5) days after the date
on the notice, unless the individual shows they did not receive the notice
within the five (5) day period;
(c)
May be extended beyond ninety (90) days for individuals declaring a non-citizen
status, 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.
(66) "Redetermination" means a review of
eligibility outside of regularly scheduled renewal. Redeterminations that
result in the assignment of a new renewal date are considered
renewals.
(67) "Renewal" means a
regularly scheduled periodic review of eligibility.
(68) "Request for information (RFI)" means a
notice sent by the agency to request additional information or verification of
information. An RFI may be sent when attested information is not reasonably
compatible with information obtained through an electronic data match, or when
information or verification is needed that is not available through an
electronic data match.
(69)
"Resident of a Public Institution" means;
(a)
An individual residing 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 a
resident of a public institution when the individual is:
(A) Released on parole, probation, or
post-prison supervision;
(B) On
home- or work-release, unless the individual is required to report to a public
institution for an overnight stay;
(C) Receiving inpatient care at a medical
institution not associated with the public institution where the individual is
a resident. An individual is an inpatient when they've been admitted to a
medical institution on the recommendation of a physician:
(i) Expects to receive room, board, and
professional services in the medical institution for a 24-hour period or
longer; or
(ii) Is expected to meet
the criteria outlined in subsection (i) of this rule, but later dies, is
discharged, or is transferred to another medical or extended care facility and
does not actually stay in the medical institution for 24 hours.
(D) Residing voluntarily in a
detention center, jail, or county penal facility after their case has been
adjudicated and while other living arrangements are being made for the
individual.
(E) Residing in a
public institution pending other arrangements as defined in
42 CFR
435.1010; or
(F) Residing in an Institution for Mental
Disease (IMD), including the Oregon State Hospital and:
(i) Is under age 21;
(ii) Is age 21 but was admitted to the IMD
before their 21st birthday; or
(iii) Is age 65 or older.
(70) "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.
(71) "Shared eligibility service" means a
common or shared eligibility system or service used by a state to determine
individuals' eligibility for insurance affordability programs.
(72) "Sibling" means natural or biological,
adopted, or half or step sibling.
(73) "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.
(74) "SSA" means Social Security
Administration.
Notes
Statutory/Other Authority: ORS 411.095, 411.402, 411.404, 413.038, 414.025 & 414.534
Statutes/Other Implemented: ORS 411.095, 411.402, 411.404, 413.038, 414.025, 414.534, 411.400, 411.406, 411.439, 413.032, 414.231, 414.536, 414.706 & 414.241
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