(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
(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.
) 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.
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
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
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
regulate the effect of a
transfer of assets on a client).
An individual described in subsection (a)
or (b) of the section who is in a nonstandard living
is not assumed eligible for long-term care services if
(see OAR 461-001-0000
) resources exceed the limit
after performing the calculation under OAR 461-160-0580
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
(a) No longer meets the definition of a
child given in this section;
Moves out of state;
ends benefits; or
(d) Is eligible
for any other Medicaid program that provides OHP Plus benefits.
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
or the residency requirements (see OAR 461-120-0010
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;
34-2016, f. 9-30-16, cert. ef.
33-2017, amend filed 12/8/2017, effective
11-2018, amend filed 03/09/2018, effective
22-2018, amend filed 06/05/2018, effective
26-2019, amend filed 12/27/2019, effective
13-2020, minor correction filed 06/02/2020, effective
6-2021, minor correction filed 02/18/2021, effective
58-2021, minor correction filed 12/13/2021, effective
14-2022, minor correction filed 02/16/2022, effective
31-2022, temporary amend filed 03/09/2022, effective
4/1/2022 through 9/27/2022;
34-2022, amend filed 04/28/2022, effective
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