Or. Admin. Code § 461-135-0010

Current through Register Vol. 63, No. 12, December 1, 2024

Section 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.

(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.

Or. Admin. Code § 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; SSP 50-2022, amend filed 09/30/2022, effective 10/1/2022; SSP 40-2023, temporary amend filed 07/26/2023, effective 7/26/2023through 1/21/2024; SSP 50-2023, amend filed 11/30/2023, effective 12/1/2023

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 117-2) & Consolidated Appropriations Act, 2023 (H.R. 2617)