Or. Admin. R. 461-135-0010 - [Effective9/27/2022]Assumed 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.
(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 and becomes ineligible while pregnant is assumed 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. 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

Or. Admin. R. 461-135-0010
AFS 80-1989, f. 12-21-89, cert. ef. 2-1-90; AFS 13-1991, f. & cert. ef. 7-1-91; AFS 2-1992, f. 1-30-92, cert. ef. 2-1-92; AFS 28-1992, f. & cert. ef. 10-1-92; AFS 1-1993, f. & cert. ef. 2-1-93; AFS 2-1994, f. & cert. ef. 2-1-94; AFS 13-1994, f. & cert. ef. 7-1-94; AFS 23-1994, f. 9-29-94, cert. ef. 10-1-94; AFS 10-1995, f. 3-30-95, cert. ef. 4-1-95; AFS 13-1995, f. 6-29-95, cert. ef. 7-1-95; AFS 22-1995, f. 9-20-95, cert. ef. 10-1-95; AFS 3-1997, f. 3-31-97, cert. ef. 4-1-97; AFS 9-1997, f. & cert. ef. 7-1-97; AFS 17-1998, f. & cert. ef. 10-1-98; AFS 12-1999(Temp), f. & cert. ef. 10-1-99 thru 1-31-00; AFS 15-1999, f. 11-30-99, cert. ef. 12-1-99; AFS 3-2000, f. 1-31-00, cert. ef. 2-1-00; AFS 10-2002, f. & cert. ef. 7-1-02; SSP 1-2003, f. 1-31-03, cert. ef. 2-1-03; SSP 33-2003, f. 12-31-03, cert. ef. 1-4-04; SSP 14-2005, f. 9-30-05, cert. ef. 10-1-05; SSP 6-2006, f. 3-31-06, cert. ef. 4-1-06; SSP 12-2006(Temp), f. & cert. ef. 9-1-06 thru 12-31-06; SSP 15-2006, f. 12-29-06, cert. ef. 1-1-07; SSP 7-2007, f. 6-29-07, cert. ef. 7-1-07; SSP 10-2007, f. & cert. ef. 10-1-07; SSP 11-2007(Temp), f. & cert. ef. 10-1-07 thru 3-29-08; SSP 5-2008, f. 2-29-08, cert. ef. 3-1-08; SSP 17-2008, f. & cert. ef. 7-1-08; SSP 23-2008, f. & cert. ef. 10-1-08; SSP 26-2008, f. 12-31-08, cert. ef. 1-1-09; SSP 6-2009(Temp), f. & cert. ef. 4-1-09 thru 9-28-09; SSP 10-2009(Temp), f. & cert. ef. 5-6-09 thru 9-28-09; SSP 27-2009, f. & cert. ef. 9-29-09; SSP 41-2010, f. 12-30-10, cert. ef. 1-1-11; SSP 1-2012(Temp), f. & cert. ef. 1-13-12 thru 7-11-12; SSP 25-2012, f. 6-29-12, cert. ef. 7-1-12; SSP 24-2013, f. & cert. ef. 10-1-13; SSP 30-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14; SSP 37-2013, f. 12-31-13, cert. ef. 1-1-14; SSP 16-2014, f. & cert. ef. 7-1-14; SSP 34-2016, f. 9-30-16, cert. ef. 10/1/2016; SSP 33-2017, amend filed 12/8/2017, effective 1/1/2018; SSP 11-2018, amend filed 03/09/2018, effective 4/1/2018; SSP 22-2018, amend filed 06/05/2018, effective 7/1/2018; SSP 26-2019, amend filed 12/27/2019, effective 1/1/2020; SSP 13-2020, minor correction filed 06/02/2020, effective 6/2/2020; SSP 6-2021, minor correction filed 02/18/2021, effective 2/18/2021; SSP 58-2021, minor correction filed 12/13/2021, effective 12/13/2021; SSP 14-2022, minor correction filed 02/16/2022, effective 2/16/2022; SSP 31-2022, temporary amend filed 03/09/2022, effective 4/1/2022 through 9/27/2022; SSP 34-2022, amend filed 04/28/2022, effective 5/1/2022

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

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.