table of contents - dhs.state.or.us · fsml – 70c august 23, 2013 medical assistance programs toc...

FSML – 70C

August 23, 2013 Medical Assistance Programs TOC Page - 1

Medical Assistance Programs

Table of Contents

A. General Information

1. Date of Request (DOR)

2. Application process

3. Reviewing for multiple medical programs

4. Redetermination of medical assistance eligibility

5. Authorized representatives

6. Medical benefit plan

7. Verification of eligibility

8. Oregon residence

9. Citizen/alien status

10. Eligibility for people in correctional facilities

11. Social Security number

12. Pursuing assets

13. Financial eligibility requirements

B. Assumed Eligibility

C. Medical Assistance to Children in Substitute or Adoptive Care (SAC)


2. Specific program requirements

3. Eligibility groups

4. Financial eligibility

5. Required verification

6. Effective dates; initial month medical benefits

D. Medical Assistance Assumed (MAA)



3. Eligibility groups for MAA

4. Deprivation for MAA



E. Medical Assistance to Families (MAF)


2. Specific program requirements for MAF


4. Verification

5. Budgeting

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6. Financial eligibility for MAF


F. Extended Medical Assistance (EXT)

1. Application process for EXT

2. Specific program requirements for EXT


4. Verification

5. EXT CM coding and support

6. EXT effective date

7. EXT eligibility

G. OHP Medical Programs

1. OHP eligibility categories; overview

2. Application for OHP

3. OHP programs; eligibility requirements and standards


5. Budgeting and income standards

6. Verification


8. OHP certification period

H. Deleted August 23, 2013

I. Twelve-Month Continuous Eligibility for Non-CAWEM Children

1. Continuous eligibility for Medicaid (CEM) overview

2. Continuous eligibility for OHP-CHP (CEC) overview

J. Breast and Cervical Cancer Treatment Program (BCCTP)

1. Eligibility requirements for BCCTP

2. Application for BCCTP

3. Coding


5. When BCCTP eligibility ends

6. Retroactive medical benefits

K. CAWEM

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L. Third-Party Insurance, Healthy Insurance Premium Payments (HIPP) and Private

Health Insurance (PHI) Reimbursements

M. Types of Decision Notices

1. Types of decision notices

2. What a decision notice must contain

3. Medical program notice situations

Worker Guide MA-1: Client Maintenance System Medical Reports

Worker Guide MA-2: OHP Quick Reference Guide

Worker Guide MA-3: Citizenship and Identity Documentation Hierarchical List

Worker Guide MA-4: SSP Medical Program Incarceration Policy & Coding Matrix

Worker Guide MA-5: List of SSP Medical Program Notices

Worker Guide MA-6: Medical Start Dates

Worker Guide MA-7: OHP Standard Reservation List Overview

Worker Guide MA-8: Shelter-In-Kind, In-Kind and Earned Income

Worker Guide MA-9: OHP-OPU Notice and OSIPM Presumptive Referral Matrix

Worker Guide MA-10: BED Quick Reference Guide

FOR DMAP (DIVISION OF MEDICAL ASSISTANCE PROGRAMS) WORKER

GUIDES, PLEASE VISIT THE DMAP WORKER GUIDES WEBSITE AT:

http://www.oregon.gov/oha/healthplan/pages/data_pubs/wguide/main.aspx

FOR ADULT PROGRAMS INFORMATION, PLEASE VISIT THE APD

WORKER GUIDES WEBSITE AT:

http://www.dhs.state.or.us/spd/tools/additional/workergd/index.htm


http://www.dhs.state.or.us/spd/tools/additional/workergd/index.htm

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FSML – 70C Medical Assistance Programs A –

August 23, 2013 General Information A- 1

A. General Information

The intent of the Medical Assistance programs is to ensure low income individuals and

families in Oregon have access to medical care. The Oregon Health Authority (OHA) is

the state Medicaid agency, but medical program eligibility determinations are made by

OHA and the Department of Human Services (DHS).

1. Date of Request (DOR)

To start the application process:

A client or someone authorized to act on their behalf must contact the department

or another appropriate location with a request for benefits. This request can be in

the form of a phone call, office visit or a written request by the applicant or

another person or agency acting on behalf of the applicant;

When the online Oregon Health Plan Application (OHP 7210W) is submitted

online, it is time-stamped and a DOR established for the applicant;

The department may also initiate the application process and establish a DOR for

the client;

Hospitals call the OHP Application Center to establish a date of request (often

referred to as a “hospital hold”) when an individual is admitted. To find out if

there has been a date of request for the applicant, call the OHP Application Center

at 800-359-9517.

New applicants

Medical benefits generally begin on the DOR. The DOR for medical benefits is the date

the applicant requests medical assistance.

If the request for medical benefits is received by a department representative no later than

one business day after medical services are received by the applicant, the DOR will be

backed up to the date of medical services were received. This means that if the individual

went to a doctor or medical provider on Saturday, applied for medical on the following

Monday and was found to be eligible, medical assistance could begin on Saturday and the

medical bill might be covered. If the individual went to the hospital on Friday night,

requested medical assistance on the following Monday and was found eligible, medical

benefits could begin on the Friday they received their medical services.

To apply for medical, a person or someone authorized to act on their behalf must either

contact a branch office serving the area they live in, an outreach center, including an

authorized Federally Qualified Health Center (FQHC) or a Disproportionate Share

Hospital (DSH), or call the toll free number 800-359-9517, with a request for benefits. A

request may be in the form of a phone call, a visit to the office or in writing.

https://apps.state.or.us/mbs/

Medical Assistance Programs A – FSML – 70C

A - 2 General Information August 23, 2013

The DOR for a medical application, which is date stamped on the application form, may

also be established by a branch, by the toll-free operator or by a worker at an outreach

center. For OHP 7210W online applicants, a DOR is established when the OHP 7210W is

successfully submitted by the applicant over the internet and received by the department.

For new applicants, in order to maintain the original DOR, the person's application form

must be received in a branch office no later than 45 calendar days from the DOR. If the

45th

day falls on a weekend or holiday, the application must be received the following

working day. If the application is not received within 45 days, the actual date the branch

office receives the application becomes the new DOR.

DOR at redeterminations

For redeterminations, the DOR is the date the application is received by the department,

the date the client establishes a DOR or the date the department establishes a DOR for the

client (for example, when acting on a reported change or when the Medical Notice: It’s

time to renew your medical benefits (DHS 945) is mailed). When the DHS 945 is sent to

clients, the department establishes the DOR on behalf of the client. The DOR is shown on

the UCMS screen and on the DHS 945.

Note: The requirement to submit a written application within 45 days of the original

DOR applies to new applicants only. Ongoing clients have a written application

already on file.

Randomly selected OHP Standard Reservation List applicants

Persons randomly selected from the OHP Standard Reservation List can establish a DOR

on or after their selection date through 45 days from the date the OHP 7210R is mailed. If

the OHP Standard Reservation List Applicant does not establish a DOR within 45 days

from the date the OHP 7210R is mailed, the client may request to be considered for an

ADA accommodation. See Multiple Program Worker Guide MP #13 (MP-WG#13) for

more information about ADA accommodations. If the client does not qualify for an ADA

accommodation, treat as a new OHP-OPU applicant.

SEE MA-WG#7 FOR MORE INFORMATION ABOUT THE OHP STANDARD

RESERVATION LIST PROCESS.


Do not require an interview for medical applicants. If the client does not show up for a

TANF, SNAP or other nonmedical-related appointment, do not deny the request for

medical. Complete the medical application process through the mail or by phone as

needed.

Applicants who are pregnant and those with emergent medical needs have priority

when processing applications for medical. They do not need to disclose the basis of their

emergent need. The application should be pended, approved or denied by the eligibility



https://apps.state.or.us/cf1/DHSforms/Forms/Served/DW0945.pdf



http://dhsforms.hr.state.or.us/Forms/Served/he7210r.pdf

http://dhsforms.hr.state.or.us/Forms/Served/he7210r.pdf

http://apps.state.or.us/caf/fsm/13mpwg13.htm

http://dhsmanuals.hr.state.or.us/EligManual/PDF/08ma-wg7.pdf



worker within one business day whenever possible. If more information is needed, it may

be necessary to pend or call the applicant.

If the medical assistance applicant does not have a companion case in a local field office,

fax the completed, date-stamped application to OHP at 503-373-7493.

The application process is complete when the person completes, signs and submits the

application, and provides the necessary information and verification within 45 days from

the DOR. The 45-day limit may be extended when circumstances exist beyond the

control of either the person applying or the department that prevent them from

completing the eligibility determination process within the time frame.

Brand new medical program applicants who are not receiving any DHS program benefits

must complete a new application.

A child who is aging off of another program or a medical case at age 19 must sign and

complete an initial medical application of their own.

New medical program applicants who already have an open DHS program case do not

need to complete a new application. The eligibility worker can request any verification or

information necessary for the medical eligibility determination without requesting a new

application if the individual has ongoing benefits from SNAP, ERDC or TANF.

People may withdraw their application at any time.

Who must sign the application?

The application must be signed by an adult member of the filing group or their

authorized representative before medical benefits may be approved;

Do not pend for signatures solely to deny the medical application;

When there is not an adult in the filing group or an authorized representative, the

person applying must sign the application. This is often the case when the

applicant is a homeless teen. This also pertains to a teen living with a relative other

than a parent, when the teen chooses to apply on their own. The teen‟s signature is

sufficient.

Example: Amy, a high school student who is 15 years old, lives with her

grandmother, Betty. Amy applies for medical benefits on her own.

Amy is the primary person applying, and is responsible for providing

necessary information to determine eligibility. Because she has not

chosen to apply with her grandmother, nor has her grandmother

chose to apply for Amy, we would process the application for Amy

on her own. There is no MAA eligibility since there is not a

caretaker relative in the filing group. We would look at OHP.



Pend end dates

OHA and DHS are committed to increasing the number of children in Oregon with access

to health benefits. We need to do everything we can to ensure families have an

opportunity to clear eligibility for their children, including providing sufficient time for

parents to respond to the pend notice.

For medical programs, the applicant is entitled to the full 45-day pend period. Do

not pend to have eligibility items returned earlier than the 45th

day following the

date of request. If the application is being reviewed close to the 45th

day following

the date of request and more information is required for the eligibility

determination, allow at least 10 business days for an applicant to respond;

Sometimes 45 days is not enough. If the pend notice is sent late for a reason

outside the client's control (application temporarily lost by the agency, late

processing because of workload, etc.), the original 45 days should be extended as

necessary to allow for some extra time. The DOR remains the same;

To extend the 45 days, you must provide the applicant with a new pend notice that

gives the new date the requested information will be due. You must also narrate

your decision and the reason it was outside the client's control.

3. Reviewing for multiple medical programs

Workers must review for all medical programs when evaluating for initial medical

eligibility, when acting on timely reported changes and at regularly scheduled

redeterminations.

When reviewing for medical eligibility:

First consider all medical programs except OHP, CEM and CEC;

If not eligible, then evaluate for OHP. For non-CAWEM children under age 19, if

not eligible for OHP, evaluate for CEM and CEC.

4. Redetermination of medical assistance eligibility

Redetermination is the process used to review eligibility to approve, close or deny the

continuation of benefits. This process includes a review of the new or existing application

and supporting documentation. It also includes an evaluation of eligibility for all Self-

Sufficiency medical programs prior to ending benefits. People must cooperate in the

process or their benefits will stop.

Special Child Welfare (CW) referral process: When children lose eligibility for foster

care, CW will open medical for the child on the CEM program, and then refer the case to

the self-sufficiency medical program worker to review for other potential eligibility. If



the child is not eligible for any other medical program, they will remain on the CEM

program for the remainder of their 12 months continuous eligibility period.

Frequency of redeterminations: Redetermination is done at assigned intervals,

whenever eligibility becomes questionable or when acting on a change that affects

current medical eligibility.

Periodic redeterminations are done every 12 months for the MAA and MAF

programs;

Children receiving Continuous Eligibility for Medicaid (CEM) or Continuous

Eligibility for CHIP (CEC) are redetermined at the end of their CEM or CEC

period;

Periodic redeterminations are done at least every 12 months for BCCM;

There is no redetermination for EXT;

OHP redeterminations are based on the OHP certification periods;

For all SSP medical programs, a redetermination is required whenever a change

has been reported timely that affects current medical eligibility;

In the MAA, MAF, OPU, OPC, OP6 and CHIP programs, redeterminations may

be done early if it is at the time of SNAP recertification. This allows the medical

program 12-month end date to match the clients SNAP 12-month certification end

date. To ensure that children under age 19 have a 12-month period of eligibility,

do not adjust the MAA/MAF redetermination date to match SNAP or another

companion case redetermination date at any other time than the SNAP

recertification.

The decision to redetermine the medical program case is up to the worker. The worker

may choose not to redetermine the medical companion case when establishing a

12-month SNAP certification period. However, if the client establishes a DOR within

45 days of the budget month, proceed with the redetermination for medical assistance.

If the clients are eligible for the same or a higher level of benefits, new MAA, MAF,

OPU, OPC, OP6 and CHIP 12-month eligibility periods may be established.

In the OPU, OPC, OP6 and CHIP programs, if the redetermination results in ineligibility

or if clients do not respond to pend notices, allow the original OPU, OPC, OP6 and CHIP

certifications to continue.

In the MAA and MAF programs, if the new redetermination decision results in

ineligibility for continued MAA or MAF benefits, the worker will need to act on the new

information to convert to another program or close.

Example 1: Mary and her three children are receiving SNAP benefits. Their

SNAP certification will expire September 30. The three children

are receiving CHIP and OP6, due to end December 31, 2011. The



worker decides to recertify the CHIP/OP6 medical so the

CHIP/OP6 medical end date matches the 12-month SNAP

certification end date. The worker recertifies SNAP, CHIP and

OP6 through September 2012.

Example 2: Heather and her two children are receiving MAA benefits and

SNAP. Heather reapplies for SNAP. Heather’s family is certified

for 12 months for SNAP. The worker determines the family is also

still eligible for MAA and matches the MAA end date with the

SNAP end date.

Example 3: Manuel, his wife and child are receiving SNAP, OPU and OPC

medical. The SNAP certification is due to expire March 31, 2011.

The OPU medical is due to end June 30, 2011. The OPC medical

is due to end December 31, 2011. The worker opts to redetermine

OPU and OPC medical as part of the SNAP recertification. As a

result of the new eligibility decisions, the worker determines the

family is eligible for SNAP, OPU and OPC. The OPC, OPU and

SNAP benefits are recertified for 12 months, through March 2012.

Example 4: Francisco and his two children apply for SNAP benefits in October

2010. Francisco’s children are receiving CHIP through March

2011. The worker determines the family to be over-income for

SNAP and the medical income to be over the 201 percent FPL. The

worker denies the SNAP benefits and the children remain on the

original CHIP certification period through March 2011.

Example 5: Sierra and her child Sammy are receiving SNAP and MAA

benefits. Their SNAP certification is expiring May 31. The MAA

benefits are expiring December 31. During the SNAP intake in

May the worker determines the child’s absent father has moved

back into the home and pends for income verification and

deprivation information (Sierra did not have this available at the

SNAP intake). The pended information is not returned. Because the

worker cannot determine that Sierra and Sammy are still MAA

eligible, the worker ends Sierra and Sammy’s medical benefits

sending a 10-day close notice.

Note: The CM system will automatically close program P2 MAA and MAF cases based

on the MAA or MAF need/resource end date on CMUP and will send the “CR”

close notice. The CM system will automatically close MAA/TANF cases if the only

child was an unborn or the only eligible child is turning 19. The CM system also

automatically ends MAA for dependent children turning 19, even if there are

other dependent children on the case. CM will not close if there is a protected

AEN or pregnant woman.

The CM system will close the HKC subsidy and HKC ESI eligibility based on the

KCR need/resource end date.



Special redetermination process for MAA/TANF companion case clients

MAA cases with companion TANF cases will not be mailed the DHS 945 or an

Application for Services (MSC 415F) reapplication packet.

When the MAA redetermination is coming due, the CM system will automatically

update the MAA N/R (need/resource) for another 12 months. This will only

happen if there is an ongoing companion TANF case;

If the TANF case closes but there is ongoing MAA eligibility, the CM case will be

converted from a program 2 or 82 to a P2 MAA only case;

When the MAA N/R end date is updated a notice will be sent to the client letting

them know their MAA benefits have been renewed and reminding them to report

changes.

DHS 945 redetermination process: The DHS 945 pend notice replaces the MSC 415F

redetermination packet for many CAF SSP medical program clients.

When processing a DHS 945, treat it as a redetermination pend notice:

- Review the client‟s application, CM case information, WAGE, ECLM,

Work Number and other available information;

- Consider if the DHS 945 reports any changes that might affect eligibility;

- If more information is necessary, send an additional pend notice using the

same 45th

day on the DHS 945, as long as it provides at least 10 business

days to provide the requested information. You may extend the pend end

date to provide the client 10 business days to provide the information;

- Narrate as a redetermination, including budget month, income calculation,

eligibility decision and other pertinent information.

Medical clients excluded from the DHS 945 process:

APD medical program cases will not be included in the DHS 945 mailings;

SSP children turning 19 who need their medical redetermined will continue to be

mailed the OHP 7210;

SSP medical cases with a companion SNAP case that is expiring the same month

or month before the medical case will receive the MSC 415F. The medical case

will be automatically updated with a DOR of the 15th

of the month prior to the last

month of the eligibility period and a BED code for the month following the last

month of the eligibility period.


https://apps.state.or.us/cf1/DHSforms/Forms/Served/me0415f.pdf









http://dhsforms.hr.state.or.us/Forms/Served/he7210.pdf




There is usually no need for a new application at redetermination/recertification

Clients who are currently receiving a DHS program (even if the program is not a medical

program) do not need to complete a new OHP 7210 or MSC 415F application when

requesting medical.

It does not matter when the application was originally signed, as long as the client is

currently receiving DHS program benefits at the time they make the request for medical.

Review the existing OHP 7210 or MSC 415F and all the information on the original

application. Determine what eligibility items need to be verified and pend if necessary.

If there is no current application available in the imaging system or in the client‟s file, or

the applicant does not have any program benefits open, require a completed application.

Amending the original application: Sometimes an application may need to be amended.

If someone has moved into the household and is in the medical filing group, the worker

may pend to have the existing application updated by the client. (When a client updates

an existing application, the client is amending the application).

To request the application be amended to include the new filing group member's name,

SSN, DOB and other information in the “Tell us about the people in your household”

section of the MSC 415F or question 2 of the OHP 7210, send copies of the pages of the

MSC 415F or OHP 7210 that need to be amended to the client with a pend notice.

Instead of sending copies of part of the original application, caseworkers may use the

Additional space for other people living with you (MSC 415X) or Additional People

(OHP 7226) (paper only) form.

Example: Mary and her three children are receiving SNAP benefits. Mary

loses her health insurance and requests medical. The worker may

use the MSC 415F used for the SNAP application to determine

eligibility for medical.

Pending for a new application: If there have been several changes to the filing group

since their last application was completed, the eligibility worker may feel a new

application is necessary. If requesting a new application, completion of that application

becomes an eligibility requirement. The family must be pended for completion of the new

application.

If the client submits a new application packet, a new signature is also required. For

example, a client who is currently receiving benefits turns in an application to renew

medical. The application must be signed. If it is not signed the application should be

pended for a signature.

In a two-parent household, at least one parent needs to sign the reapplication.









https://apps.state.or.us/cf1/DHSforms/Forms/Served/de0415x.pdf




Do not use the signature on the old application when there has been a break in medical

benefits.

Example: Joan and her two children are receiving SNAP and ERDC. Joan

reports that her husband John has returned to the household. Joan

requests medical for herself, John and their two children. The

worker may use the MSC 415F used for the SNAP eligibility to

determine eligibility for medical.

However, the worker needs information about John. The worker may

amend the existing application by pending for current information,

or the worker may opt to pend for a new application

Bypass End Date (BED) coding for periodic redeterminations or when acting on a

reported change: For periodic redeterminations or when acting on a reported change that

affects medical eligibility in the BCCM, CEC, CEM, EXT, MAA, MAF, OHP, OSIPM

and SAC programs, give the filing group 45 days from the date of request to re-establish

their eligibility. If the client indicates that more time is required to get necessary

verifications, extend the due date.

Note: Although the client's report of a change must be timely in order to be eligible for

an extension to the 45-day application processing time frame, a state agency's

report of a change need not be timely.

If there is not enough time to process the periodic redetermination or act on the reported

change, add the BED. The BED end date should provide enough time to pend and/or send

a 10-day notice to close or reduce benefits.

Note: Clients who receive the DHS 945 will have their CM system case automatically

updated with BED coding.

If not removed, the CM case will use the BED code to send the 77B 10-day close notice

on the 15th

of the month. If the 45th

day is after the 15th

, the BED end date should be the

following month.

The BED coding works correctly only when there is a medical end date to bypass. If

necessary, change the medical end date to the current month. For example, if the MAA

need/resource end date is 12/12 and the client reports a change requiring MAA

redetermination in 07/12, send the pend notice, change the MAA end date to 07/12 and

add the BED code.

SEE MEDICAL ASSISTANCE WG-10 (MA-WG#10) FOR MORE INFORMATION

ABOUT BED CODING.

If the client has turned in enough information to make an eligibility determination

and is still eligible, but for a reduced benefit package: The worker will need to send a

timely continuing benefit notice. Remove the BED coding, and compute the client into

the correct program with a 10-day notice to reduce benefits.



http://dhsmanuals.hr.state.or.us/caf/fsm/pdf/08ma-wg10.pdf



Example 1: CW notifies you the only eligible child has been removed from the

MAA household; medical benefits must be redetermined for the

adults for OHP-OPU eligibility. If necessary, add the BED coding

to the adults MAA case and pend as needed to verify OHP-OPU

eligibility. If eligible for OHP-OPU, send a timely continuing

notice of reduction, Notice of Decision or Action. Remove the BED

code and transition the parents into the OHP-OPU program for

the first of the month after the timely continuing notice period.

Example 2: Ted’s three children are at the end of the CHIP eligibility period.

At redetermination, it is determined that they are now HKC

eligible as the financial group’s income is between 201 to

301 percent FPL. Add the BED coding and KCA coding to each

child on the CM case. The CM system will automatically refer the

children to OPHP. The referral notice includes information about

the reduction.

If the client is not eligible for SSP medical anymore, but could be eligible for APD

medical: When a decision has been made that the client is no longer eligible for SSP

medical, did they indicate a disability? If they could be eligible for APD medical,

complete a referral. If already receiving SSP medical, keep the SSP medical open until

APD has made a decision. Use the BED coding to keep the case open. Do not send a

close notice or DHS 462A until APD has made a decision.

If the client's case has to be pended: Once the BED coding has been added to a pended

case, if the client does not return the requested information by the 45th

day, the CM

system will automatically send a timely close notice telling them there isn‟t enough

information available to determine eligibility and so their medical benefits will close. The

worker will not need to send a separate close notice. No DHS 462A is required.

Reminder: If information needed to determine eligibility is expected to be received

after the 45-day deadline due to circumstances the client has no control

over, the 45-day application processing time frame may be extended.

Periodic Redeterminations; Not EA, ERDC, EXT, OHP, REF, REFM, SNAP or TA-DVS: 461-115-0430

Specific Requirements; OHP: 461-135-1100

Reservation Lists and Eligibility; OHP-OPU: 461-135-1125

Acting on Reported Changes; EXT, MAA, MAF, OHP, OSIPM, QMB, SAC: 461-170-0130

Effective dates: Redeterminations of CEC, CEM, EXT, MAA, MAF, OHP, OSIPM, QMB, SAC:

461-180-0085

5. Authorized representatives

A person or family may use an authorized representative to complete the application for

them if needed. Examples of people who can be authorized representatives are legally

appointed guardians, conservators, a person with power of attorney, a person authorized

http://dhsforms.hr.state.or.us/Forms/Served/de0462a.pdf

http://dhsresources.hr.state.or.us/WORD_DOCS/DE0462A.doc

http://dhsmanuals.hr.state.or.us/A/461-115-0430.htm

http://apps.state.or.us/caf/arm/A/461-135-1100.htm


http://dhsmanuals.hr.state.or.us/B/461-170-0130.htm




by the recipient or a person acting responsibly for the recipient. If needed, the branch

may appoint a responsible person to be the authorized representative.

To designate an Authorized Representative or Alternate Payee, the client must complete

the Designation of Authorized Representative or Alternate Payee (MSC 231) at the time

of the application or at any time the client requests a change. If health information is to be

disclosed, an Authorization for Use and Disclosure of Information (MSC 2099) is

required in addition to the above mentioned forms.

6. Medical benefit plan

People eligible for a medical assistance program will receive:

The OHP Plus benefit package – a comprehensive medical plan;

The OHP Standard benefit package – a benefit plan similar to private health

insurance; or

For clients ineligible for full benefits because of their immigration status, a

medical benefit package that covers emergent medical needs only.

The benefit package a person receives is determined by the program for which they are

eligible. Individuals eligible for BCCM, CEC, CEM, EXT, MAA, MAF, OHP (except

OHP-OPU), OSIPM and SAC receive a Plus benefit package.

Individuals eligible for Healthy KidsConnect program (HKC) receive benefits through

the Office of Private Health Partnerships (OPHP). The benefits are similar to OHP Plus;

however HKC families are responsible for paying for part of, or all of the insurance

premium.

Individuals eligible for OHP-OPU receive the OHP Standard benefit package.

Individuals eligible for a Medicaid program except for their noncitizen status receive the

Citizen/Alien-Waived Emergent Medical (CAWEM) benefit package. Individuals

eligible for CAWEM are only eligible for emergency medical benefits.

Individuals eligible for QMB have limited benefits specific to Medicare coverage.

FOR MORE INFORMATION REGARDING BENEFIT PACKAGES, GO TO

HTTP://WWW.OREGON.GOV/OHA/HEALTHPLAN/PAGES/TOOLS_STAFF/MAIN.A

SPX AND CLICK ON DMAP WORKER GUIDE. SCROLL DOWN TO DMAP WORKER

GUIDE #4.

https://apps.state.or.us/cf1/DHSforms/Forms/Served/me0231.pdf

https://apps.state.or.us/cf1/DHSforms/Forms/Served/me2099Enabled.pdf

http://www.oregon.gov/oha/healthplan/Pages/tools_staff/main.aspx

http://www.oregon.gov/oha/healthplan/Pages/tools_staff/main.aspx

http://www.oregon.gov/oha/healthplan/tools_staff/worker-guide.pdf

http://www.oregon.gov/oha/healthplan/tools_staff/worker-guide.pdf



7. Verification of eligibility

The intent of requesting verification is to ensure that the verbal or written information

given by a person is accurate.

People must provide verification of their eligibility when requested. Branch staff may

determine what is acceptable as verification for specific eligibility requirements and

situations. An application may be denied or ongoing benefits ended when acceptable

verification is not provided; however, federal policy is clear that ongoing medical clients

are “eligible until no longer eligible.” When pending, be sure to list the reason(s) why

eligibility needs to be verified. Narrate the eligibility factors that need verification.

For all medical assistance programs, verify the following whenever it is reported,

changed or as needed for eligibility determination:

Pregnancy. This must be verified by a medical practitioner, a health department or

clinic, or a crisis pregnancy center or other similar facilities. Due date verification

is not required except when the only child is an unborn child for MAA and MAF,

or when a CAWEM client is part of the Pre-natal Expansion Program (see NC-C.3);

Birth of a child (report of the child‟s birth);

Amount of the premium for available health insurance;

Citizenship. When an applicant claims U.S. citizenship, it must be verified. To

determine if a medical program applicant meets the citizenship requirements, first

check the citizenship field on Person Alias/Update. If not already documented,

check the BBCN screen. If not born in Oregon, enter a TPQY request on the

TPQY Request Screen. In order to submit a request, the client must have already

been added to the CI system (must have a WEBM FIND record).

If unable to document citizenship, and the client is otherwise eligible for medical,

do not delay opening medical. Send a pend notice (such as the CMCITPD Notice

Writer notice) and add the CIP N/R item and CIP case descriptor to each person

needing documentation.

If the client does not provide documentation, the CM system will send a close

notice and end benefits. The policy applies to all medical program clients,

including pregnant women who were opened and then required to provide

documentation, but did not do so.

Once a client‟s medical has been closed for failure to provide citizenship

documentation, unless they have good cause, they must provide documentation

before they receive benefits again.

Noncitizen status. Acceptable evidence of noncitizen status must be provided. If

the client is unable to provide documentation at initial application and declares a

noncitizen status that meets the requirements, open medical benefits, code with the

http://apps.state.or.us/caf/fsm/15nc-c.htm#CAWEM



NOP N/R, and pend for documentation. If the client does not provide

documentation, the CM system will send a close notice and end benefits. The

policy applies to all medical program clients, including pregnant women who were

opened and then required to provide documentation, but did not do so.

Re-verify noncitizen documentation at each eligibility determination.

Once a client‟s medical has been closed for failure to provide noncitizen

documentation, unless they have good cause, they must provide documentation

before they receive benefits again.

Note: The NOP/NOE/NOD process applies only to clients who have not provided

documentation but who have 1) declared a status that meets the alien status

requirements; OR 2) have provided an “A” number that SAVE indicates meets the

alien status requirement.

Income. For the OHP (including OPU), MAA, MAF and SAC programs, obtain

verification of the source of the income to support the client‟s statement about

earned and unearned income. This is different than asking for proof of the dollar

amount of the earned income;

First, try to verify the source of earned and unearned income using information

already available on Work Number or available computer screens including

SMUX, ECLM, DPPL, SSNX, W204, etc.

If no other supporting documentation is available, ask for one recent pay stub or

payment verification from the budget month to verify the income source. If the

client has more than one job or an unearned income source, ask for one piece of

supporting documentation from each job or income source.

If verification is not available from the budget month, ask for a recent pay stub or

other pay verification from the current source of income. Other items that can be

used to verify the income source include the WAGE screen, phone call with the

employer or letter from the employer, SSA award letter, VA award letter, etc.

In absence of other forms of verification, accept the client‟s statement and narrate.

For example, the client has just started a new job and has not yet been paid. The

employer is out of town due to a family emergency and the client is unsure when

they will return. The client‟s statement may be written or oral. Statements the

client makes on the application are considered written.

Example 1: The applicant is paid on the first and 15th

of the month. DOR is the

seventh. The worker is processing the application on the 10th

. To

determine countable income, add actual gross income paid on the

first (as reported by the applicant) and anticipated gross income

for the 15th

. To verify the source of income and to validate the

client’s statement of income, use a recent copy of the pay stub, or

any verification submitted.



Example 2: Client has a brand new job and has not been paid yet. For the

countable income calculation, use anticipated income from the

budget month. Do not require any verification for the anticipated

income source; accept the client’s verbal or written statement.

Example 3: New applicant has two part-time jobs and received pay from both

jobs in November and December. She is paid every Friday for

job #1 and every other Friday for job #2. Her DOR is

December 15. Use income already received and anticipated

income in December for the countable income calculation. To

verify the income source and validate the client’s statement, ask

for documentation such as a pay stub from each job. If the client

says “I can’t find a pay stub,” accept another form of verification.

Verification of self-employment costs is not required for OHP and MAF unless

questionable. When a self-employed individual applies for medical assistance:

Intent: Verify the source using the individual‟s statement of self-employment on the Self-

Employment Income application (DHS 859B) or similar statement.

Validate the individual‟s self-employment income statement by asking for some

additional documentation (such as bookkeeping records, copies of contracts, or

copies of work agreements and sales);

If there is no additional documentation available, accept the individual‟s statement

but request the individual begin to keep better business income and expense

records.

Example 4: Client is self-employed and reports $15,000 from their business in

the initial budget month, which is under the $20,000 business

income entity test. The worker needs documentation of the self

employment income and can use the completed application,

DHS 859B, MSC 943, or similar documentation along with

available verification such as: bookkeeping records, copies of

contract, copies of work agreements and sales receipts. In the

absence of other forms of verification, accept the client’s statement

and narrate.

For all other eligibility requirements (i.e., residence, age, resources), accept the person's

statement unless it is questionable or inconsistent.

Any eligibility requirement may require verification when information is questionable or

inconsistent with any of the following:

Other reported information;

Other information provided on the application;

Other information received by the branch office;

https://apps.state.or.us/cf1/DHSforms/Forms/Served/DE0859B.pdf

http://dhsforms.hr.state.or.us/Forms/Served/de0859b.pdf

https://apps.state.or.us/cf1/DHSforms/Forms/Served/de0943.pdf



Information reported on previous applications.

8. Oregon residence

To be eligible for medical assistance, people must be residents of Oregon. They must be

currently living in Oregon and intend to remain in the state. There is no requirement that

they must have been in Oregon or intend to remain in the state for a minimum amount of

time. Residents can leave the state for temporary purposes (e.g., vacation, school

attendance, medical treatment, employment) and keep their residency as long as they

intend to return to Oregon.

A new resident receiving medical assistance from another state may receive duplicate

medical assistance from Oregon, if the person would be eligible in Oregon and would not

otherwise receive medical care. In these cases, support your decision with a narration in

TRACS.

Residency Requirements: 461-120-0010

Incapable of Stating Intent to Reside; EXT, HKC, MAA, MAF, OHP, OSIPM, QMB, REFM and SAC:

461-120-0050

Concurrent and Duplicate Program Benefits: 461-165-0030

9. Citizen/alien status

Alien requirements overview

To determine if an applicant meets the alien status requirements (vs. CAWEM), see

section C.1 of the Noncitizens Chapter (NC-C.1) or Noncitizens Worker Guide #1

(NC-WG#1).

People not applying for medical benefits, or CAWEM applicants who are not

documented (do not have a legal immigration status) are not required to declare or

provide proof of their citizenship or immigration status. The disclosure of information

regarding citizenship and alien status for nonapplicants is voluntary.

Note: Nonapplicants are persons who choose not to apply for benefits or who are not

eligible to receive benefits, even though they may be required to provide

verification of income and resources.

To be eligible for the CAWEM program, a client must be ineligible for EXT, MAA,

MAF, OHP (except OHP-CHP), OSIPM or SAC solely because they do not meet

citizenship or alien status requirements. See section C.3. in the Noncitizens Chapter

(NC-C.3)




http://apps.state.or.us/caf/fsm/15nc-c.htm#AlienStatus

http://apps.state.or.us/caf/fsm/15ncwg1.htm

http://apps.state.or.us/caf/fsm/15nc-c.htm#CAWEM



Citizenship and alien status documentation requirements

On the medical program application, applicants for Medicaid and CHIP declare whether

or not they are U.S. citizens. If they declare they are a U.S. citizen, most applicants‟

citizenship must be documented. If they declare they are not a U.S. citizen, but that they

have a legal immigration or INS status, they must provide proof of their noncitizen status.

Some Medicaid and CHIP clients are considered to have met the U.S. citizenship

documentation requirements already and do not need to provide evidence of citizenship.

These individuals include:

SSI recipients;

Medicare recipients;

SSDI recipients;

Assumed eligible newborns (AENs) born in Oregon. Using „AN‟ as the source

code on Person Alias/Update identifies AENs. An AEN who moves here from

another state is not an AEN in Oregon. Children under age one who apply for

medical in Oregon as a new resident have to meet citizenship and SSN

requirements like everyone else who applies;

Tribal members whose tribe resides in the U.S. Using „TM‟ as the source code on

Person Alias/Update identifies tribal members whose citizenship has been

documented by proof of tribal membership.

Application processing prior to receiving citizenship/alien status verification

The application requirements are the same for persons declaring U.S. citizenship and

persons that declare a noncitizen legal status that meets the alien status requirements.

Instead of waiting for the citizenship or alien status documentation, if the Medicaid or

CHIP applicant is otherwise eligible for Medicaid or CHIP, do not delay issuing medical.

For new applicants, attempt to verify citizenship through BBCN or TPQY prior to

pending for verification. For those whose citizenship cannot be verified through

BBCN or TPQY, pend for citizenship documentation for 45 days from the date of

request. Open medical benefits for those who are otherwise eligible;

If an applicant or recipient can get the documentation, but needs extra time, it is

possible to authorize an extension of the 45-day pend period. Always provide a

new pend notice with a new pend due date, and track the progress. Determine what

new pend date to use by jointly determining with the client the length of time you

both believe will be necessary;

If the client is required to provide citizenship or alien status documentation and

does not provide it within the time allowed, and does not request an extension, the

benefits will automatically close medical assistance and send the timely closure

notice, based on the CIP or NOP coding;



If they reapply for medical, determine if there was good cause for not having

provided documentation earlier. If there is no good cause, the applicant must

provide documentation before their medical can be reopened.

Notices and CM System coding

CIP/CIE/CID coding for Citizens: If pending for documentation of citizenship and/or

identity, enter the pend information on the Notice of Pending Status (DHS 210), Notice of

Information or Verification Needed (DHS 210A), CMCITPD, CMNCSPD or other

notice. Add the CIP (citizenship pend) N/R to each person needing documentation. If

necessary to provide additional time, repend and convert the CIP to CIE (citizenship pend

extended). If documentation is provided remove the CIP or CIE coding. If documentation

is not provided and the client does not have good cause the CIP/CIE coding will prompt

the CM system to send an 80B close notice and end benefits based on the CIP or CIE end

date, and the case will be coded with CID (citizenship closed or denied).

NOP/NOE/NOD coding for Qualified Noncitizens: Acceptable evidence of noncitizen

status must be provided, but if the client is unable to provide documentation at initial

application and declares a noncitizen status that meets the requirements, open, code with

the NOP (noncitizen pend) N/R and pend for documentation.

If an applicant or recipient can get the documentation, but needs extra time, it is possible

to authorize an extension of the 45-day pend period. Be very careful to provide a new

pend notice with a new date and to track progress. Determine what new pend date to use

by jointly determining with the client the length of time you both believe will be

necessary and reasonable. Convert the NOP to NOE (noncitizen pend extended).

If the client does not provide documentation, the CM system will send a close notice and

end benefits, and the case will be coded with NOD (noncitizen closed or denied). The

policy applies to all medical program clients, including pregnant women who were

opened and then required to provide documentation, but did not do so.

Example 1: Maria applied for medical for herself and one child on April 15.

Her child is a U.S. citizen, verified via BBCN. Maria’s

identification of her child’s DOB and place of birth are on the

application. Maria declares she is an LPR, and states her LPR

status began 10 years ago. She meets the alien status requirements,

but cannot find her I-551 card. Maria and her child are MAA

eligible except Maria needs to provide proof of her LPR status and

DOE. Open MAA for Maria and her child. Pend Maria to provide

documentation, and code case with NOP.

Example 2: Jane is receiving CHP benefits when her mother, Ann, lost her job

and applied for TANF/MAA on April 15. Ann's citizenship

documentation is the only item remaining for Ann’s MAA

eligibility. Convert Jane and Ann to MAA and add the CIP to both

Jane and Ann.

http://dhsforms.hr.state.or.us/Forms/Served/de0210.pdf




Example 3: Bill applied for OHP for his two children on March 15, 2011. The

children are eligible for OHP except that Bill lost his children's

citizenship documentation from California, and the worker is

unable to get the verification from the TPQY screen. Open the

children's OHP-OPC medical effective March 15 and pend for the

necessary documentation. Add the CIP coding to each child with

an end date of April 2011.

Recording documentation

You may receive original documentation by mail or in person. If mailed, place a copy in

the case record and return original documents via regular mail. Often these documents

say they are not to be copied, but a state agency can make a copy for the client‟s file.

You may also be provided documentation from contracted outreach facilities and

application assister programs including: Application Assistance Program, Outreach and

Enrollment Grant Program, Volunteer Organizations and CHIPRA Application Assisters

Program. Outreach facilities and application assister programs can attest they have

viewed the original citizenship and identity documents. They use the U.S. Citizenship and

Identity Proof Documentation (OHP 7203) (paper only) form to verify which documents

they have viewed. We can accept the OHP 7203 when it is date-stamped by the outreach

center or application assister and bears the outreach facility or application assister

identification code.

DHS and OHA have made a commitment that there will be “no wrong door” for

applicants and recipients who are providing documents. If an individual brings original

documents to any DHS or OHA office or branch, even when the client's case is in another

branch, the following steps must be taken:

Accept whatever original documents or certified copies from issuing agencies the

client brings in;

Copy and return the original documents to the client;

Date stamp the copies, make a note on them that we have viewed the original

documents (some branches have a date stamp that already says this) and sign or

initial;

Some branches review the documents provided, and if the documents meet the

requirements of citizenship and identity, they update the CI Person/Alias Update

screen before sending the copies to the appropriate branch. This is a decision that

can be made on the branch level;

Narrate in TRACS that the client brought in documentation. If it is going to be sent

to another branch, narrate what the documentation was and what branch it is being

sent to;

If an individual provides fraudulent citizen/noncitizen related documentation, we

are required to report it to the agency that issued the document. For example, if a



fraudulent birth certificate is submitted, notify the issuing state's vital records

agency.

Once documented, we should not need to verify a client's U.S. citizenship status again.

The expectation is that the citizenship field on Person/Alias Update will be a key tool in

tracking citizenship documentation. If you look on Person/Alias Update and the

citizenship field indicates acceptable verification has been provided, you do not need to

re-verify citizenship.

Noncitizens who declare a legal immigration status and request full benefits need to have

their immigration status verified at every redetermination.

Copies of the accepted documents should be included in the case record. As previously

noted, we can photocopy passports and other documents marked “Do not copy” for our

files.

The case record includes:

Imaged documents;

Case file;

Updated citizenship field on the client's Person/Alias Update screen Citizenship

Field.

The Person/Alias Update citizenship field must be updated to reflect citizenship or alien

status. Reports, audits and other reviews use information available on the citizenship

field.

Acceptable citizenship documentation

States are required to use the most reliable form of citizenship documentation available.

A hierarchical list has been provided when the verification cannot be obtained from

BBCN or the TPQY screen.

SEE WORKER GUIDE MA#3 (MA-WG#3), CITIZENSHIP AND IDENTITY

DOCUMENTATION HIERARCHICAL LIST FOR THE COMPLETE HIERARCHICAL

CITIZENSHIP DOCUMENTATION LIST.

Federal guidance encourages states to use information available on BBCN or the

TPQY screen as reliable documentation of citizenship;

“Primary documents” from the hierarchical list are considered the most reliable

and may be used to document both citizenship and identity;

If the citizenship documentation is not available on BBCN or the TPQY screen,

and it is determined that the client cannot obtain a higher level citizenship

documentation within 45 days from the DOR, accept lower level documentation.

Do not pend for higher level documentation;

http://dhsmanuals.hr.state.or.us/EligManual/pdf/08ma-wg3.pdf



If the applicant or recipient needs to order birth certificates from out of state,

provide the list or the link to state vital records contacts at:

http://www.cdc.gov/nchs/w2w.htm.

SEE FSM MULTIPLE PROGRAM WORKER GUIDE MP#3 (MP-WG#3) VITAL

STATISTICS FOR A LIST OF OUT-OF-STATE VITAL RECORDS CONTACTS.

Hardship criteria

In certain limited circumstances, we may be able to help assist with payments for

citizenship documentation.

Pay via the Authorization of Cash Payment (MSC 437) using pay reason 30 or SPOTS

object code 4961. We can pay when the individual is unable to pay for the required

documentation due to:

Gross income is at or below 10 percent of the federal poverty level (FPL); or

Liquid resources are less than $100; or

When income, less shelter and utilities, is less than 10 percent FPL; or

When the client is homeless; or

When there is domestic violence.

In circumstances where the individual meets one of these hardships, but has a resource to

pay the cost of documentation, allow them to pay for the documents. We will not

purchase driver's licenses in place of state I.D. We will not pay for passports or

naturalization papers except in very rare circumstances. Consult a Medical Program

analyst before paying for passports or naturalization papers.

Payments cannot be made to reimburse the applicant or recipient.

To order a birth certificate for clients meeting the hardship criteria:

Go to the CDC “Where to Write for Vital Records” website at:

http://www.cdc.gov/nchs/w2w.htm. The website has links to each state's vital

records for birth certificate requests;

Follow the state's instructions for ordering a birth certificate and complete the

required letter or form. The requirements vary by state; for example, some states

require the client or the client's parent sign a statement authorizing the request for

a birth certificate;

Mail the required letter or form requesting the birth certificate. Enclose a pay

reason 30 revolving-fund check in the required amount.

http://www.cdc.gov/nchs/howto/w2w/w2welcom.htm

http://www.cdc.gov/nchs/howto/w2w/w2welcom.htm

http://dhsmanuals.hr.state.or.us/EligManual/13mpwg03.htm


http://www.cdc.gov/nchs/w2w.htm



Oregon vital records screens

Access to Vital Records screens is limited to viewing. NEVER PRINT VITAL

RECORDS SCREENS! Narration and updating citizenship documentation fields on the

Person/Alias Update screen fully meets the documentation requirements.

We have been given access to screens that provide birth, marriage and divorce data.

Birth and Death screens:

The Oregon Vital Events Registration System (OVERS) was implemented

January 28, 2013, replacing birth and death screens previously available on the

DHS mainframe. Additional information regarding OVERS can be accessed on the

OVERS Information for State Employees website;

The parent‟s birthplace listed on OVERS is self-disclosed and does not meet

documentation requirements;

You may need to confirm name changes to verify identity.

Marriage screens:

BMBW – Browse by bride;

BMBH – Browse by groom;

BMBD – Browse by date of marriage.

Divorce screens:

BABW – Browse by wife;

BABH – Browse by husband;

BABD – Browse by date.

SEE THE COMPUTER GUIDE CHAPTER XIII(C) FOR MORE INFORMATION ABOUT

THE VITAL RECORDS SCREENS.

Verifying citizenship using the TPQY Request screen

To determine if a medical program applicant meets the citizenship requirements, first

check the citizenship field on Person Alias/Update. If not already documented, check the

BBCN screen. If not born in Oregon, enter a TPQY request on the TPQY Request

Screen.

To access the TPQY Request Screen:

Select the {F23} TPQY key on the BEIN screen; or

https://or-vitalevents.hr.state.or.us/OVERS/Logon.aspx

https://public.health.oregon.gov/BirthDeathCertificates/RegisterVitalRecords/overs/Pages/StateUsers.aspx

http://www.dhs.state.or.us/policy/selfsufficiency/cg_security.htm



On a clear screen, enter WQY1 and press {enter}; or

On a clear screen, enter WQY1, SSN and press {enter}.

On the TPQY Request screen:

Enter the SSN if necessary, your branch I.D. and worker I.D.;

Press {F9} to save.

Results will usually display in the “Citizenship Code” field on the W204 screen the next

business day. If the TPQY request was entered after 2:00 PM, the response will display in

two business days.

To view the citizenship code field:

Enter WQY2, SSN or WQY2, branch number ID and press {enter};

Select the response line (or SSN/CAN line) and press {enter};

The Citizenship Code field will display on the W204 screen directly above the

Verification Code field.

TPQY citizenship codes:

“A”: The client‟s U.S. citizenship is documented by SSA and meets the medical

program citizenship documentation requirements. The SSA has no record the

client has died;

“B”: The SSA has determined the client‟s declaration of U.S. citizenship is not

consistent with SSA documents. (SSA has some documentation the client is not a

U.S. citizen.) The SSA has no record the client has died;

“C”: The client‟s U.S. citizenship is documented by SSA and meets the medical

program citizenship documentation requirements. SSA records indicate the client

has died;

“D”: The SSA has determined the client‟s declaration of citizenship is not

consistent with SSA documents. (SSA has some documentation the client is not a

U.S. citizen). SSA records indicate the client has died;

“Blank”: A blank Citizenship Code means the SSA does not have any citizenship

related documents. The client may be a U.S. citizen, but the SSA could not verify

citizenship. A blank Citizenship Code could also mean the request has not been

submitted to the SSA or that the SSA has not responded to a request yet.

If the response is “A” or “C,” citizenship is verified. Update the client‟s Person

Alias/Update screen with an “SR” citizenship source code and narrate.



If the medical program application states the client is a U.S. citizen but the SSA response

is “B,” “D” or “blank,” citizenship is not documented. Send the client a pend notice (such

as the CMCITPD Notice Writer notice) and add the CIP coding to each person needing

documentation and narrate.

The Citizenship/Alien Status fields on the Person/Alias Update Screen

To access the Citizenship field on Person/Alias Update, go to the client's CI-FIND

screen. Press F16.

There are three fields that are used to support citizenship.

The first field is the “Cit” field. The Cit field indicates if client has met the Medicaid/

CHIP required documentation of citizenship or noncitizen status, including identification

requirement:

An “A” in the Cit field means that the client has provided “Acceptable

documentation” and has met the Medicaid/CHIP and HKC documentation

requirements. The client has declared U.S. citizenship and provided the approved

Medicaid/CHIP documentation of citizenship and identification or the citizenship

has been documented by the Social Security Administration;

A “D” in the Cit field means the client has declared U.S. citizenship but has not

yet provided documentation;

An “X” in the Cit field means the client has not requested Medicaid/CHIP medical

assistance or that no information is available;

A “C” in the Cit field means the noncitizen has not yet met alien status

requirements (if otherwise meets the Medicaid program requirements may receive

CAWEM benefit package). A document source code is not allowed for persons

with a “C” in the Cit field;

An “N” in the Cit field means noncitizen who meets Medicaid/CHIP alien status

(noncitizen) requirements, i.e., and is eligible for full medical benefits (is not

limited to CAWEM). A documentation source code is not allowed for persons with

an “N” in the Cit field.

Note: Do not code a Refugee with an “N.”

The “V/R” field indicates whether the documentation has been reported but not verified.

A “V” means both citizenship and identity meet the requirements.

The next field identifies what source was used to report or verify citizenship and identity.

For example, “PS” is the code for passport; “BP” is the code for public birth record and

includes Vital Records screen verification such as BBCN.

To update the citizenship fields on Person/Alias Update:



Tab to the bullet to the left of the “Cit” field. Enter an X on the bullet. Press F13.

The Citizenship Update screen will display;

Enter the appropriate codes in the Cit, V/R, and Src fields. Press F9 to save;

F3 will return you to Person/Alias Update.

Application Processing Timeframes; Not Pre-TANF or SNAP: 461-115-0190

Required Verification; BCCM, EXT, HKC, MAA, MAF, OHP, SAC: 461-115-0705

Citizen and Alien Status Requirements: 461-120-0110

Alien Status: 461-120-0125

Declaration of Citizenship or Alien Status: 461-120-0130

Assumed Eligibility for Medical Programs: 461-135-0010

10. Eligibility for people in correctional facilities

An inmate of a public institution is not eligible for benefits. An inmate is a person living

in a public institution who is:

Confined involuntarily in a local, county, state or federal prison, jail, detention

facility or other penal facility, including a person being held involuntarily in a

detention center awaiting trial and a person serving a sentence for a criminal

offense;

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;

Residing involuntarily in a facility that is under governmental control; or

Receiving care as an outpatient while residing in a public institution.

A public institution is an institution for which a governmental agency has responsibility

or exercises administrative control. Administrative control includes but is not limited to

ownership and control of the physical facilities and grounds used to house inmates. A

governmental agency exercises administrative control when it is responsible for the

ongoing daily activities of a facility; for example, when facility staff members are

government employees, or when a governmental agency, board, or officer has final

authority to hire or fire employees of the institution. As used in this section, public

institution relates to individuals residing in a correctional facility and not a medical

facility.

Effective June 1, 2011, new policy was implemented to suspend benefits for inmates

expected to be incarcerated for less than a year with a basic decision notice. The effective

date is the date the decision is made to suspend the benefits and the date the notice is

sent.

Note: The agency is notified on December 5 that Dante was incarcerated on

December 1. The worker sends a notice to suspend Dante’s benefits on









December 5. The effective date on the notice is December 5 and the medical end

date on the CM case is December 5.

When released, the inmate is required to report within 10 days of the release in order for

benefits to be restored. If the inmate does not report timely and no good cause exists,

medical benefits cannot be restored.

If circumstances have changed while the inmate was incarcerated, upon release, an

immediate redetermination of eligibility will be necessary after a former inmate‟s

benefits have been restored. Examples are:

An MAA client does not return to the family with a dependent child upon their

release;

An inmate returns home to family with OHP benefits but is now eligible for MAA;

When an inmate was receiving OHP and the redetermination date occurs while

they were incarcerated.

An individual is no longer an inmate when:

The person is released on parole or probation;

The person is on home- or work-release, unless the person is required to report to a

public institution for an overnight stay; or

The person is staying voluntarily in a detention center, jail or county penal facility

after his or her case has been adjudicated and other living arrangements are being

made for the individual.

For more information on how to treat a client who becomes incarcerated with an expected

stay of a year or less, refer to Worker Guide MA#4: SSP Medical Program Incarceration

Policy & Coding Matrix (MA-WG#4).

Eligibility for Inmates and Residents of State Hospitals: 461-135-0950

Notice Situation, Nonstandard Living Situations: 461-175-0230

Incarcerated pregnant women receiving medical assistance

An inmate as described above is not eligible for benefits. However, a pregnant woman

determined eligible for Medicaid assistance is assumed eligible for medical assistance

through the date her pregnancy ends.

If a pregnant woman receiving Medicaid assistance becomes an inmate of a public

institution, her medical benefits are suspended. However, her medical eligibility

continues as an assumed eligible pregnant woman. Upon notification the pregnant woman

has been released, her medical benefits are restored without an application if she

continues to reside in Oregon.

http://dhsmanuals.hr.state.or.us/EligManual/pdf/08ma-wg4.pdf





To suspend medical benefits for a pregnant woman who becomes an inmate of a public

institution:

Create a separate medical case for the pregnant woman if she is not already on her

own case;

Use the “SUSM” incoming code to suspend medical benefits. The case will remain

in suspense status for six months before the case is auto-closed showing a

“SUSPCL” incoming code;

Use the “IN” reason code and “IN” notice code. The notice code will initiate the

“IN” CMS notice (Pregnant female benefits suspended - Incarceration);

Add the “INM” case descriptor to the case.

To restore the pregnant woman's medical benefits upon notification she is no longer an

inmate of a public institution:

Start medical eligibility effective the first day she is no longer an inmate of a

public institution;

Remove the “INM” case descriptor from the case;

If she was released while still in her eligibility period, but does not report it to

DHS until after her eligibility period has ended, complete a Request for

Retroactive Eligibility (MSC 148) form for the date of her release through the end

of the protected eligibility period, and submit it to Client Maintenance Unit.

When An Application Must Be Filed: 461-115-0050


Eligibility for Inmates and Residents of State Hospitals: 461-135-0950

11. Social Security number

To be eligible for medical benefits, most applicants must provide a Social Security

number (SSN) or verify they have applied for one as a condition of eligibility. Applicants

who do not have to meet the SSN requirement include:

CAWEM applicants;

Individuals who may only be issued an SSN for a nonwork reason, including

Medicaid and CHIP clients under the age of 19;

Assumed eligible newborn (AEN) children during their AEN-protected eligibility

period; or;

Individuals who are a member of a religious sect or a division of the sect are not

required to provide an SSN if it is against their religious beliefs;







Individuals who are fleeing domestic violence may need to apply for a new SSN

and may have a period of time without an SSN.

Nonapplicants do not have to meet the SSN requirement. It is only on a voluntary basis

that a nonapplicant provide their SSN. Nonapplicants are persons who choose not to

apply for benefits or who are not eligible to receive benefits, even though they may be

required to provide verification of income and resources.

If an applicant who is required to meet the SSN requirements has not been issued an

SSN, assist the applicant in applying for an SSN. If an applicant does not recall their

SSN, assist the client in verifying the number.

Note: Eligibility workers are required by federal law to assist medical program

applicants to apply for an SSN.

SEE MULTIPLE PROGRAM WORKER GUIDE #2 (MP-WG#2), VERIFYING CLIENT

INFORMATION.

Do not deny or delay medical benefits to an otherwise eligible applicant pending the

issuance or verification of an individual's SSN. However, if an applicant is required to

meet the SSN requirement, and refuses to apply for or provide an SSN, the applicant is

not eligible for benefits.

Note: Code the NSR case descriptor for each recipient exempt from the requirement to

provide an SSN due to religious reasons and recipients who would only be issued

an SSN for a nonwork reason. The NSR code will prevent the computer system

from automatically generating a close notice and ending benefits due to a

“missing” SSN.

Example 1: Sandy is requesting medical for herself and her daughter Mandy.

An SSN was not provided for Mandy; Mandy is not exempt from

the requirement to apply for or provide an SSN. The only

remaining pending item is proof that Mandy meets the SSN

requirement. Open medical for Sandy only. Send a DHS 210 pend

notice requesting proof that an SSN has been requested for Mandy

or for disclosure of Mandy’s SSN.

Example 2: James, his wife Lani, who is pregnant, and their 2-year-old son

Jamison, are noncitizens from Africa currently residing in Eugene

under a student visa while James attends University of Oregon.

Medical benefits are requested for Lani and Jamison. Lani and

Jamison’s I-94 reflects an F-2 Class of Admission. They are not

work-authorized and would only be issued an SSN for a nonwork

reason; therefore, they are exempt from the SSN requirement.

Assuming all eligibility requirements are met, Lani would be

eligible for CAWEM Plus Pre-natal medical. Jamison’s status is





reflected on Noncitizen Chart C and is therefore eligible for full

benefits. Add the NSR case descriptor for Jamison.

Requirement to Provide Social Security Number (SSN): 461-120-0210

12. Pursuing assets

To be eligible for medical assistance, people must actively pursue assets for which they

have a legal right or claim, i.e., unemployment compensation, workers compensation,

Social Security benefits or any third party which may be liable for payments. However,

people applying for one of the department's programs are not required to apply for other

programs it administers. Persons eligible for CEC, CEM, EXT, MAA, MAF or SAC are

not required to pursue SSI benefits.

To pursue assets, they must apply for and satisfy all requirements to receive benefits from

other programs. They must also pursue legal remedies to obtain assets from any other

source if they can secure legal counsel on a contingency fee basis. People do not have to

pursue loans.

People who do not pursue assets that they may be entitled to, and do not have good cause,

are not eligible for medical assistance. This ineligibility ends when they provide evidence

that they are willing to cooperate. Only the individual who can pursue the asset is

assessed the penalty and loses medical eligibility. Other individuals in the benefit group,

such as other adults or children, continue to receive medical assistance.

For example: Unless there is good cause not to pursue, clients who have been in car

accidents must help pursue third-party coverage. Clients may be pended for Vehicle

Related Personal Injury (MSC 451) or Non-Vehicle Related Personal Injury

(MSC 451NV) forms.

Pursuing UC

Unemployment compensation (UC) is a key asset. Most clients applying for or receiving

CEC, CEM, EXT, MAA, MAF, OPC, CHP, OPP and OPU and SAC are required to

pursue UC if it could be an available asset.

As with other assets, pursuing UC means applying for UC and, if eligible, meeting the

Employment Department work search (or other) requirements. The eligibility worker can

accept the client‟s statement that they have applied for UC benefits. This applies to

potential UC claims within Oregon and from another state. If an individual does not have

good cause not to pursue UC, that person is not eligible for SSP medical program

benefits.

If it is later discovered the client did not follow through with meeting the Employment

Department‟s requirements, after considering good cause, it may be necessary to end

their medical benefits.



http://dhsforms.hr.state.or.us/Forms/Served/de0451nv.pdf



When the worker pends for pursuit of UC, the notice should include a statement directing

the client to contact the worker if they have concerns about applying for UC.

Example: Dave and his children apply for medical benefits. Dave has a

potential UC claim and is pended to pursue this claim. Dave

contacts the worker and indicates he has applied for UC. Dave has

met the requirement to pursue UC. Dave and his children meet all

other eligibility requirements and are determined eligible for MAA.

Two months later Dave files a SNAP application. Upon review of

SNAP eligibility, the worker determines Dave did not continue

pursuing his UC claim. The eligibility worker considers whether or

not Dave had good cause not to pursue the UC claim by calling the

client. The eligibility worker determines there is no good cause.

Dave is sent a 10-day close notice and a DHS 462A to end his

benefits.

Example: John is receiving OPU and reapplies for medical benefits. John has

a potential UC claim and is pended to pursue this claim. John

contacts the worker and indicates he has applied for UC. John has

met the requirement to pursue UC. John meets all other eligibility

requirements and is determined eligible for OPU. Two months later

John files a SNAP application. Upon review of SNAP eligibility, the

worker determines John did not continue pursuing his UC claim.

Whether or not John has good cause to not pursue the UC claim, his

benefits will continue through the remainder of his eligibility period.

At the next redetermination evaluate whether or not John has a

potential UC claim. If he does have a potential claim and does not

have good cause not to pursue UC, consult with a medical policy

analyst to determine what John will need to do to meet the

requirements of pursuing UC and what to put on the pending notice.

Example: Gloria and her family are on EXT. During the EXT period of

eligibility, Gloria contacts her worker to report that she lost her job

(This is not on the required reporting list for EXT.) Worker notes

they may be MAA eligible if deprivation exists, and pends for

necessary information and pursuit of UC. Gloria does not respond.

No further action is required. The worker cannot determine if

deprivation exists for MAA for the filing group, so the family

continues on EXT through the remainder of their EXT eligibility

period. At redetermination, the worker will review to see if Gloria

should pursue assets.

Pregnant women and pursuit of UC

Unless the pregnant woman has good cause or is receiving TANF and determined

to be JOBS exempt, require pregnant women at initial application (not yet

receiving Medicaid benefits) to pursue UC. Do not open medical assistance until

the pregnant woman has met the requirement to pursue UC;

https://apps.state.or.us/cf1/DHSforms/Forms/Served/DE0462A.pdf



When a pregnant woman is eligible for and receiving Medicaid, she has protected

eligibility and cannot be penalized for refusing to pursue UC during her protected

eligibility period. Do not require ongoing pregnant Medicaid recipients to pursue

UC as part of their eligibility for Medicaid.

Note: The Oregon Employment Department will not deny a UC applicant due solely to

their being pregnant. Many claimants who are pregnant tell OED they are unable

or unavailable to work all hours. They are not denied because they are pregnant,

rather due to how they answer OED’s questions. In these cases, consider if the

individual has good cause for not pursuing UC; if there is no good cause, and it is

at initial application, deny the applicant for failure to pursue UC.

Applicants

MAA/MAF applicants may notify you they will not apply for UC. If an

MAA/MAF applicant lets you know they choose not to apply for UC, determine if

the client has good cause for not applying. If they do not have good cause, deny

just the applicant who refuses to apply. Do not deny anyone else in the filing group

such as the children or second parent;

If you have pended the MAA/MAF applicant to pursue UC and the applicant does

not contact you about the UC requirement during the pend period, the entire filing

group is denied assistance. You can let the CM system deny everyone on the

application for failure to complete the application process (“DD” or “AP” denials).

The denial is not for failure to pursue UC, but because the client did not

complete the application process;

For OHP, if the adults are not applying for OHP for themselves, or if they are

applying for OHP-OPU and ineligible because they are new applicants, do not

pend the adults for pursuit of UC.

Recipients

When pending a client at redetermination, add the BED coding and send the pend notice

to require the client to pursue UC. The pend notice should include a statement directing

clients to contact the worker if they have concerns about applying for UC. Notice Writer

notice GS0UCPD can be used when pending clients to apply for UC.

If there is more than just UC pended for and the client does not respond to the

redetermination pend notice, let the CM system send the 77B BED close notice

and end benefits for everyone in the household for failure to complete the

redetermination process. The CM system will not end benefits for clients who have

protected eligibility, such as AENs or women still in their protected eligibility

period. The closure is not for failure to pursue UC, but because the client did not

complete the redetermination process;

For MAA/MAF, if there is ongoing medical and the only item pended for was

pursuit of UC, BED the case. If they do not respond to the pend, the 77B will be

send and the BED date will close the entire need group. If they do respond and tell



you they will not pursue the UC, ask if there is a good reason. If no good cause for

nonpursuit, close only the person who refuses to pursue UC.

For OHP only, if there is an ongoing OHP-OPU client and the only item to pend

for is UC, recertify everyone else in the household. Pend the ongoing OHP-OPU

client for UC and add the BED coding. Do not update the STD N/R end date.

If the client is pended for pursuit of UC and does not respond to the pend notice,

the CM system will send the 77B BED close notice and end benefits for that client.

CM will end benefits only for the person(s) whose medical was not recertified. It

will not end medical for pregnant women or AENs.

Caution: If there is no ongoing OHP-OPU client, do not pend the adults for UC.

For EXT, MAA, MAF and OHP at redetermination/recertification, if a recipient notifies

you that they choose not to apply for UC, determine if the client has good cause for not

pursuing. If no good cause:

Send a 10-day close notice and the DHS 462A and end the recipient's medical

benefits. Do not end the benefits for anyone else on the case because the recipient

refused to apply for UC. If the recipient is pregnant, do not require her to pursue

UC as part of her medical redetermination.

For ongoing medically eligible clients not at redetermination:

If an ongoing EXT, MAA or MAF client reports a change that indicates they might

be eligible for UC, pend the client for pursuit of UC, unless pregnant. If they do

not respond, send a 10-day notice and DHS 462A and end their benefits.

Guidance for determining good cause

For CEM, EXT, MAA, MAF and OHP, if the client has been pended for pursuit of UC

and contacts the department within the 45-day pend period with concerns about applying

for UC, consider if the client has good cause for not pursuing UC before denying or

ending benefits. To qualify as good cause, there must be a circumstance beyond the

client‟s control for not pursuing.

Reasons for good cause include but are not limited to:

An individual in the ninth month of pregnancy or experiencing a medical condition

due to pregnancy. Accept the client‟s statement of a medical condition unless

questionable;

An individual who is unable to obtain or maintain appropriate child care and there

is not another caretaker in the household who can provide child care;

There is a recommendation by Child Welfare or other agency that the client should

not work;





An individual who is in the JOBS program and determined to be JOBS exempt;

An individual going to school and in the Parents as Scholars (PAS) program;

An individual who is a teen parent and in high school through the JOBS program;

A teenager who is attending high school or high school equivalent program;

An individual who is staying home to provide care to a disabled household

member;

A noncitizen who cannot legally work in the U.S. Even if the individual was

working under an acquired social security number, they do not have a legal right to

pursue UC; or

An individual working 30 hours or more per week.

Reasons that would not be considered good cause include:

An applicant applying for the first time who is pregnant and not in the ninth month

or experiencing medical complications due to pregnancy;

An individual attending college is not sufficient good cause. Oregon Employment

Department does not automatically deny a UC applicant because they are attending

college;

An individual working less than 30 hours a week; or

An individual who reports they quit their last job and indicates they will not be

eligible for UC due to the job quit. There are many times a claimant is approved

for UC benefits when they quit their last job. Let the Employment Department

make the decision.

Frequently asked questions and answers

Question 1: Can DV applicants receive medical benefits without having to apply for

UC?

Answer 1: Yes, you can give them good cause not to apply if it appears they are not

available to look for work because of DV issues.

Question 2: An MAA/TANF client in JOBS is attending high school; does she have to

apply for UC?

Answer 2: JOBS exempt clients do not have to pursue UC (OAR 461-120-0330).

Mandatory JOBS clients are required to pursue UC. However, pursuing UC may

interfere with a teen mom’s JOBS plan. If that is the case, make a determination of good

cause, and narrate.




Question 3: Do I have to pend an OHP client for UC, even if it wouldn‟t affect their

budget month income?

Answer 3: At field request and to streamline eligibility, nonapplicants or those who are

not eligible are no longer required to pursue UC. Applicants who may or have been

determined to be otherwise eligible for medical are required to pursue UC.

Question 4: What if my client tells me he is not going to pursue UC?

Answer 4: If he is a new MAA/MAF applicant and refuses to apply for UC, we do not

need to pend him for pursuit, but we do have to consider whether he must be denied MAA

or MAF. First, consider if he has good cause. If he does not have good cause for refusing

to apply for UC, deny only him, and open the children and any other parent on the case

(the penalty for failure to apply for UC only applies to the person that does not apply for

UC). Send him a denial notice explaining the UC issue and a DHS 462A. The person who

refused to pursue UC is still in the need group; his income and resources still affect the

family's eligibility.

If he is an ongoing MAA/MAF client at redetermination and he refuses to apply, send him

a close notice and a DHS 462A and continue the review process for the rest of the family.

Let him know he can change his mind, pursue UC and get back on MAA/MAF if the

family is still eligible.

Question 5: My MAA client is pregnant. Does she need to pursue UC?

Answer 5: Yes, she does at initial application, unless she is exempt from JOBS

participation. (JOBS-exempt clients do not have to pursue UC). If she has health

concerns or is unable to look for work, you can give her good cause not to apply for UC.

Do not pend pregnant clients already receiving Medicaid to apply for UC. Technically,

they are required to pursue UC, but since they are eligible for and receiving Medicaid as

a pregnant woman, they have protected eligibility status. We cannot end their benefits

because they refused to apply for UC now. Rather than create extra workload, the policy

decision is not to require pregnant recipients to apply for UC at later dates in their

protected eligibility period.

Question 6: Why make MAA/MAF clients apply for UC if their WBA (weekly benefit

amount) will not affect their medical anyway?

Answer 6: It is a federal requirement for Medicaid. Also, WBA calculations expire. We

cannot know for sure what the current WBA amount is. It is better to have the client

apply, let the Employment Department figure it all out and then make a decision.

Question 7: My MAA client is working part time and I know he is not eligible for UC

because his earnings are over the WBA amount. Is he required to apply for UC?

Answer 7: Yes, have him apply for UC. Let the Employment Department make the

decision. There are lots of variables about UC that we do not know.





Question 8: My MAF client is a college student. He did not quit a job to go to school but

since he is in school I know he cannot get UC. Must he apply for UC just to be denied?

Answer 8: The Employment Department does not automatically deny UC just because the

applicant is a student. He needs to apply for UC. If he refuses, deny his medical with a

denial notice and DHS 462A and open for the rest of the family.

Question 9: My MAA client quit work to go to school. Do I still need to make him apply

for UC?

Answer 9: Yes. For EXT, MAA, MAF and OHP clients, quitting a job does not

automatically make the client ineligible for UC. If he refuses to apply for UC, he will no

longer be eligible for CAF SSP medical. In that case, send a 10-day close notice and a

DHS 462A and end his medical benefits. Narrate your decision.

Question 10: My MAA client applied for UC and I opened the case, but then he did not

follow up on the UC.

Answer 10: If he does not have good cause, send a 10-day close notice and a DHS 462A

and end his benefits.

Note: Frequently, there is a time lag from the time the client initially applies for UC and

the time the medical is opened. Before opening, check on the UC screens to see if

the client is actually pursuing the UC. If not, then determine if the client has good

cause. If no good cause, deny just the person who did not pursue UC.

Question 11: What if my single-parent MAA client does not want to look for work right

now?

Answer 11: Unless she has good cause for not looking for work, send her a pend notice.

If she does not start pursuing UC, send a 10-day notice of reduction and DHS 462A and

end her medical. (Do not end medical for her children.)

Question 12: My MAA CWM client just lost his job. Do I need to pend him for UC?

Answer 12: Yes, but only if he could be eligible for UC. Do not pend if UC is not an

available asset. For example, if he is using someone else's SSN or does not have a work

permit, it is not an available asset and there is no reason to pend him. Narrate why you

did not require him to apply.

Requirement to Pursue Assets: 461-120-0330

Determining Availability of Income: 461-140-0040

Personal Injury Claim: 461-195-0303

Pursuing assets; health care coverage and cash medical support

To be eligible for medical assistance, most people must pursue available health care

coverage or cash medical support for members of the benefit group. Requirements vary







http://dhsmanuals.hr.state.or.us/C/461-195-0303.htm



by program, depending upon whether the asset is health care coverage or cash medical

support.

Health care coverage cooperation

Cooperation in pursuing health care coverage includes, but is not limited to: applying for,

accepting, and maintaining all available cost-effective health care coverage and

identifying and providing information to the department in obtaining health care benefits.

Medicare: Adult clients must make a good-faith effort to obtain coverage under

Medicare.

Pursuing claims for damages: Adults must pursue a claim for damages from personal

injuries, including the completion of the Vehicle Related Personal Injury (MSC 451) and

Non-Vehicle Related Personal Injury (MSC 451NV) personal injury forms.

Employee-sponsored health care coverage: Cooperation with health care coverage

means that persons (except for pregnant women, OHP-CHP-eligible individuals, OHP-

OPU-eligible individuals and persons excused for good cause) eligible for medical

assistance are required to:

Apply for, accept and maintain cost-effective, employer-sponsored health

insurance.

Insurance is considered cost-effective when the employee's share of the premium is equal

to or less than the Cost-Effective Health Insurance premiums (HIP) standard. Effective

January 1, 2012, the definition of Cost-Effective Health Insurance changed. If the

insurance is not cost-effective, the person cannot be required to apply for or accept the

insurance.

OHP-OPU clients: Cooperation with health care coverage includes the requirement that

OHP-OPU clients cooperate with the FHIAP application process. In the OHP-OPU

program, a person (except for American Indians/Alaska Natives; persons eligible for

Indian Health benefits; and persons eligible under CAWEM) who has group health

insurance available (but is not enrolled) through an employer is required to:

Cooperate in determining eligibility for the Family Health Insurance Assistance

Program (FHIAP). Under FHIAP, a person receives a monthly subsidy to cover a

portion of the person's health insurance premiums;

If eligible for FHIAP, the person must apply for and accept the health insurance

and enroll all OHP-OPU recipients on the case who are eligible for the insurance.

Eligibility under the OHP-OPU program ends and the person receives assistance for the

health insurance premiums under FHIAP. If not eligible for FHIAP, the person is not

required to enroll in their employer's insurance and, if otherwise eligible, continues to

receive benefits under the OHP-OPU program.


http://dhsforms.hr.state.or.us/Forms/Served/de0451nv.pdf



OMIP/FMIP: The Oregon Medical Insurance Pool (OMIP) and Federal Medical

Insurance Pool (FMIP) work together to provide a high-risk health insurance pool for the

state. OMIP/FMIP is guided by a citizen board of directors and was established by the

Oregon Legislature to cover adults and children who are unable to obtain medical

insurance because of health conditions.

OMIP/FMIP also provides a way to continue insurance coverage for those who exhaust

COBRA benefits and have no other options.

OMIP/FMIP contracts with Regence Blue Cross-Blue Shield as the health insurance

provider for OMIP/FMIP recipients.

Except for OHP-OPU and OHP-CHP, DHS medical program clients can have

OMIP/FMIP. However, per OMIP/FMIP rules, coverage is not allowed to overlap with

Medicaid or CHIP as it is private major medical health insurance. Clients may incur an

overpayment with OMIP/FMIP if they receive Medicaid or CHIP at the same time.

OMIP/FMIP clients are considered to have a condition that, without treatment, would be

life-threatening or would cause permanent loss of function or disability. If the

OMIP/FMIP client applies for Medicaid or CHIP, workers should review the client‟s

OHP-OPU medical application to determine if they are eligible for a waiver of the six-

month waiting period following the receipt of private major medical health insurance

under the provisions of OAR 461-135-1100:

Workers should review the client‟s OHP-CHP medical application to determine if

they are eligible for a waiver of the two-month waiting period following the

receipt of private major medical health insurance under the provisions of OAR

461-135-1100.

To avoid overlap and client overpayment, once determined otherwise eligible for

Medicaid or CHIP, DHS/OHA workers should email Regence Blue Cross/Blue Shield at

[email protected] and copy Sandy Harris at [email protected]

to verify the termination date of the private major medical health insurance. Include the

following information:

Client name;

Social Security number;

If possible, CareAssist or Regence I.D. Number;

DOR of DHS medical application;

Applicant has been determined eligible for Oregon OHA/DHS medical insurance.

To help clients avoid an OMIP/FMIP overpayment and/or overlap of Medicaid

with private major medical health insurance, their OHA/DHS medical should not

http://www.oregon.gov/oha/OPHP/OMIP/Pages/index.aspx



mailto:[email protected]




begin until their OMIP/FMIP has ended. OHA/DHS medical will be started on the

day following their termination date.


Cash medical support: Cash medical support is cash ordered to aid the custodial

caretaker in meeting medical needs for the child. Cash medical support is part of the

requirement to cooperate with the Division of Child Support (DCS) and is included in the

“Cooperation with the Division of Child Support” subsection below.

Cooperation with the Division of Child Support

Applicants for Medicaid assistance are required to agree to cooperate with the DCS to

obtain health care coverage or cash medical support for their child through a noncustodial

parent, unless they have good cause not to cooperate.

Exceptions to the requirement to cooperate with the DCS:

Parents of OHP-CHP children are not required to cooperate with the DCS;

Pregnant women are excused from cooperating with the DCS;

Persons with good cause not to cooperate with the DCS (see the Good Cause

subsection below).

Most Medicaid clients cannot be required by the department to complete paternity

affidavits or pursue health care coverage or cash medical support at initial application or

at redetermination of Medicaid eligibility. Signing the application is proof the client has

agreed to cooperate. However, if the DCS sanctions an adult applicant for failure to

cooperate during the application process, the adult applicant who failed to cooperate is

denied. Use the CSM case descriptor to identify applicants denied for failure to

cooperate.

What cooperation with the DCS includes

Medical program recipients (except OHP-CHP clients, pregnant women and persons

excused for good cause) are required to:

Assist DHS/OHA and the Department of Justice, Division of Child Support in

establishing paternity for a child and obtaining health care coverage and cash

medical support;

Assign cash medical support payments to DHS/OHA. Once Medicaid coverage for

a child receiving cash medical support begins, the Division of Child Support will

send the cash medical support payment to DMAP.

Note: See the Child Support chapter for information on the assignment process and how

to identify the cash medical support payment.


http://www.doj.state.or.us/dcs/Pages/index.aspx






http://dhsmanuals.hr.state.or.us/EligManual/EMnlFrame.htm?Page+ID=09-toc



Applying the penalty for noncooperation with health care coverage and cash

medical support

Adults that do not cooperate and do not have good cause are not eligible for medical

assistance. There is no ineligibility for pregnant females who refuse to cooperate.

Note: Medical-only clients may be disqualified for failure to pursue a cash medical

support order. They cannot be disqualified for failure to pursue cash support not

specifically dedicated to medical expenses.

Additionally, only the individual who can legally assign rights and obtain the insurance is

assessed the penalty for failure to meet this requirement, or in other words, loses medical

eligibility. The other individuals in the group, such as other adults and children, continue

to receive Medicaid.

Ineligibility for medical assistance ends when the person provides evidence that they are

willing to cooperate.

Good cause for not cooperating with the Division of Child Support

A person is excused for good cause from the requirement to obtain health care coverage

or cash medical support from the Division of Child Support if:

Cooperation would result in emotional or physical harm to the dependent child or

to the person. The person's statement alone is sufficient evidence that harm would

result. Additional evidence is not necessary to grant good cause;

Continuing efforts to establish paternity or obtain medical support would be

detrimental to the dependent child because the child was conceived as a result of

rape or incest. The person's statement alone is sufficient evidence on the issues of

conception and detrimental effect to the child. Additional evidence is not

necessary to grant good cause;

Legal proceedings are pending for the adoption of the child;

The parent is being helped by a public or licensed private social agency to resolve

the issue of whether to release the child for adoption.

People who claim good cause for refusing to cooperate on grounds other than those listed

above have 20 days from the date of refusal to provide the statement or evidence. If they

have difficulty getting evidence, allow a reasonable time to provide the information.

Consider them to have good cause if they have made a good-faith effort to provide

verification but are unable to do so.

Medical Assignment: 461-120-0315


Clients Required to Obtain Health Care Coverage and Cash Medical Support; CEM, EXT, GAM, MAA,

MAF, OHP (except OHP-CHP), OSIPM, SAC: 461-120-0345

Clients Excused for Good Cause from Compliance with Requirements to Pursue Child Support, Health

Care Coverage, and Medical Support: 461-120-0350






http://dhsmanuals.hr.state.or.us/C/461-195-0303.htm



13. Financial eligibility requirements

Definitions of assets

An asset is either counted as income, counted as a resource, or excluded in any given

month. When an asset is excluded, it is not counted as either income or a resource. An

asset that is counted as income is excluded as a resource in that month.

When determining financial eligibility, count all assets that are not specifically excluded.

For more information on whether to count types of income or a resource, refer to the

Counting Client Assets chapter of the FSM, the MAA Asset Quick Reference Chart or

the OHP List of Income and Resources.

Assets; Income and Resources: 461-140-0010

Availability of resources

An available resource is one that the person has a legal interest in and is available to be

used for their support and maintenance. When a person states the resource is not

available, they must provide proof that it is not available.

When a resource is jointly owned, only the portion of the jointly owned resource that can

be legally attributed to the person is considered available.

A resource is not considered available in the following situations.

A person has a legal interest in the resource, but it is unavailable because it is not

in their possession;

The resource is jointly owned with other people who are not in the financial group,

who are unwilling to sell, and the person's interest is not reasonably salable;

A person is verified by a doctor to be incompetent and there is no legal

representative to act on their behalf;

A person is a victim of domestic violence and the resource is jointly owned with a

person who lives in the household the person left;

The resource is an irrevocable or restricted trust and cannot be used to meet the

person's basic monthly needs;

A person does not know they own the resource.

Availability of Resources: 461-140-0020

http://dhsmanuals.hr.state.or.us/EligManual/EMnlFrame.htm?Page+ID=10-toc

http://dhsmanuals.hr.state.or.us/caf/fsm/pdf/08ma-fchart.pdf

http://dhsmanuals.hr.state.or.us/EligManual/PDF/08ma-f_ohpchart.pdf





Treatment of excluded income

Excluded income remains excluded as long as it is kept in a separate account and not

commingled with other funds. Excluded income that is commingled in an account with

other funds that are not excluded remains excluded for six months from the date it is

commingled, after which it is counted as a resource.

When an excluded resource is sold, the proceeds from that sale are considered available

and can affect eligibility. Special rules apply to these situations. See OAR 461-145-0460.

Availability of income

Income includes both earned income from employment (including self-employment) and

unearned income from sources such as Social Security, pensions and child support.

Income is considered available immediately upon receipt, or when the person has a legal

interest in the income and the legal ability to make the income available.

Earned and unearned income is considered to be available prior to any amounts

subtracted for things such as garnishments, taxes, payroll deductions or voluntary payroll

deductions; i.e., IRAs, KEOGHs.

Earned income withheld or diverted at the request of an employee is considered available

in the month the wages would have been paid. An advance or draw is money received

that will be subtracted from later wages. An advance or draw is considered to be available

when it is received.

When a person is usually paid monthly or twice monthly on the first or last day of the

month, but is paid early or late because the regular payday falls on a holiday or weekend,

they are still considered to be paid on the regular payday.

Income that should legally be paid directly to a person, but is paid to a third party for a

household expense, is considered available to the person when the third party receives the

payment.

Income is not considered available in the following situations:

The income is withheld by an employer as a general practice, even if in violation

of the law;

The income is paid jointly to the person and other people and the others do not pay

the person their share;

The income is received by a person after they have left the household;

In the MAF and OHP programs, if the client's abuser is not in the filing group, the

abuser controls the income and will not make the income available to the filing

group;




In the MAA program, if the client's abuser controls the income and will not make

the income available to the filing group. This applies to all situations whether or

not the abuser is in the filing group.

Definitions for Chapter 461: 461-001-0000


Anticipated income amount

Consider the client‟s stated anticipated income amount:

If the client did not provide anticipated amount, call them. It is OK if the statement

of anticipated income is from the phone call;

If the client says they do not know how much they will make, ask questions about

their income and jointly determine with the client their countable anticipated

income. For example: Explain that we need gross income, not net. Ask what dates

they are paid (as opposed to pay periods) or if their work hours are changing;

It sometimes helps to refer to prior income amounts and ask the client if the new

anticipated income is likely to be the same. If the client declares their income for

subsequent paychecks will change and the change makes sense (pay increase, loss

of job, etc.), accept the client‟s statement and narrate the circumstances;

If the client‟s pay rate and anticipated work hours are available, work with the

client to calculate an anticipated income amount. Confirm the amount with the

client.

Note: For OHP, do not annualize, convert or prorate the financial group’s income at

certification or recertification. Use the OHP countable income available for the

budget month. For MAA/MAF/SAC with a new applicant, do not annualize,

convert or average the client’s income. For ongoing MAA/MAF/SAC clients,

average, annualize or convert as necessary so that each month’s anticipated

income amount is the same.







FSML – 65A Medical Assistance Programs B –

May 1, 2012 Assumed Eligibility B - 1

B. Assumed Eligibility

Assumed eligibility (who is automatically eligible or has protected eligibility?)

Some individuals are assumed eligible for certain medical programs. An individual who

is assumed eligible for a medical program does not need to complete an application or

have their eligibility determined. Their medical eligibility is not based on meeting

financial and nonfinancial eligibility requirements.

The following people are assumed eligible for medical assistance:

A pregnant woman who is eligible for and receiving medical assistance under

BCCM, CEM, EXT, MAA, MAF, OPP, OSIPM and SAC is assumed eligible until

the last day of the calendar month in which the 60th

day following the last day of

the pregnancy falls;

A child born to a mother who is eligible for and receiving Medicaid based on CW

foster care or Adoption Assistance, BCCM, CEM, CHP, EXT, MAA, MAF, OPP,

OSIPM or SAC program eligibility (including CAWEM) is assumed eligible until

the end of the month in which the child becomes one year old;

Note: CW cannot add AENs born to CW foster care or Adoption Assistance Medicaid

recipients. If requested to add an AEN born to a CW mother, please email

Medical SSP-Policy for guidance.

Children born to pregnant CHIP and CEC women should be coded as assumed

eligible newborns. Children born to HKC clients are not assumed eligible;

A child who is the subject of an adoption assistance agreement with another state;

A child in a state-subsidized, adoptive placement, if an adoption assistance

agreement which indicates the child is eligible for Medicaid is in effect between a

public agency of the state of Oregon and the adoptive parents;

A lawful recipient of SSI benefits (the client is eligible for and receiving SSI

benefits);

A client who receives both benefits under Part A of Medicare and SSI benefits is

assumed eligible for the QMB-BAS program;

A client is assumed eligible for REFM if:

- The client is receiving cash assistance through the REF program;

- The client loses eligibility for cash assistance through the REF program

only because of income or resources;

- The client loses eligibility for the EXT, MAA, MAF or SAC programs, but

still meets the requirements of the REFM program; or


Medical Assistance Programs B – FSML – 65A

B - 2 Assumed Eligibility May 1, 2012

- The client had refugee-related medical assistance established in another

state based on refugee status granted by the United States Citizenship and

Immigration Services, and moved to Oregon within the client's first eight

months in the United States.

Frequently asked questions for assumed eligible newborns and pregnant women

Question 1: If my client is already eligible for and receiving medical benefits when she

reports the pregnancy do I need to process a redetermination?

Answer 1: No, you only need proof of pregnancy.

Question 2: What if I receive a report that mom had a baby but she never reported or

verified the pregnancy?

Answer 2: If mom is eligible for and receiving BCCM, CEM, EXT, MAA, MAF, OPP,

OSIPM and SAC when her pregnancy ends, she is assumed eligible until the last day of

the calendar month in which the 60th

day following the last day of the pregnancy falls.

When the report is received, add the baby to the case as an AEN and code the mother

with the appropriate DUE month/year if she’s still within the two calendar months

following the last day of her pregnancy. If she was an OPU recipient, convert her to OPP

for the remainder of her protected eligibility.

Question 3: My client is pregnant and receiving MAF. She reported her baby’s birth but

I know the father is in the home and has really high income. What medical program

should the AEN child be coded with?

Answer 3: The AEN child should be coded with whatever program the mother is

receiving unless when the pregnancy ends. The only exception to this is when mom is

receiving OPP and there are other children on the case coded as OPC or OP6. In those

cases the AEN child should be coded as OPC or OP6 as appropriate.

Question 4: Can an AEN lose eligibility?

Answer 4: An AEN’s eligibility is protected through the end of the month in which they

turn one year of age as long as they remain in Oregon. This is true even if the child

leaves their mom’s household or is adopted.

Medical may end if a caretaker requests closure or the child is no longer a resident of

Oregon. Once closed, if the caretaker requests the AEN medical be reopened and/or the

child regains Oregon residency, restore AEN medical through the balance of the AEN

protected eligibility period.



FSML – 70B Medical Assistance Programs C –

August 1, 2013 Medical Assistance to Children in Substitute or Adoptive Care (SAC) C - 1

C. Medical Assistance to Children in Substitute or Adoptive Care (SAC)

The Medical Assistance to Children in Substitute or Adoptive Care (SAC) program

provides medical assistance to children placed in substitute care and children who are the

subject of adoption assistance agreements. Non-CAWEM SAC children may qualify for

Continuous Eligibility for Medicaid if they lose eligibility for SAC prior to their next

scheduled 12-month redetermination.

Effective September 15, 2011, Child Welfare (CW) assumed responsibility for most SAC

(C5) applications, including:

Children receiving Foster Care and Adoptions Assistance from other states who

reside in Oregon;

Healthy Kids referrals (2116 referrals);

Chafee Medical Program referrals for children aging out of Oregon Foster Care;

Tribal CW children;

Children in CW custody who are placed in Psychiatric Residential Treatment

Services (PRTS).

Branch 5503 carries the remaining C5 SAC cases, including children in Behavioral

Rehabilitation Services (BRS) and children in PRTS who are not in the custody of CW;

typically these children are referred to the PRST or BRS facility by a parent or guardian.

When a parent or guardian refers a child to drug or alcohol treatment, the child is not

considered for a C5 SAC case; they are considered for MAA, MAF, EXT, OHP, or

CHIP.


When a request is made for SAC medical assistance, use the Application for Children in

Substitute Care (MSC 1462) or the Medical Assistance Application for Children

Receiving Adoptive Assistance (MSC 1462A).

MSC 1462 applications are completed by facilities on the behalf of children in substitute

care. The MSC 1462 is also completed by foster care providers on the behalf of children

approved for foster care in another state but who are currently residing in Oregon.

MSC 1462A applications are completed by adoptive parents for children who are the

subject of an adoption assistance agreement between the parents and a public agency of

another state. These children are assumed eligible for SAC medical assistance.

When a child moves to Oregon from another state where an adoption assistance

agreement is in effect between the agency in the other state and the adoptive parents, the






Medical Assistance Programs C – FSML – 70B

C - 2 Medical Assistance to Children in Substitute or Adoptive Care (SAC) August 1, 2013

other state usually sends forms to Oregon's DHS Adoption Assistance Unit indicating the

family has moved to Oregon and is eligible for medical assistance.

When an application for a child who may be eligible for SAC is received, please fax the

completed MSC 1462, MSC 1462A, MSC 415F, OHA 7210 or SDS 539A application to

the CMED eligibility specialist at 503-945-7032.

For a child who has an immediate need for a medical ID card, please indicate "emergency

application" on the fax cover sheet.

CMED will screen the application and assign to CW or 5503, as appropriate;

Most SAC applications remain with CMED. CMED will narrate SAC eligibility in

TRACS and approve eligibility using the CM system;

The CMED team’s SAC cases will be assigned to a new branch number; 5508;

If you need to contact a CMED Eligibility Specialist, contact via DHS/OHA email

system:

Leslee V. Star [email protected]

Margaret L. Roberts [email protected]


To be eligible for the SAC program, an individual must be under the age of 21 and:

Live in substitute care covered by title IV-E of the Social Security Act;

Live in a foster care or private institutional setting for which a public agency of

Oregon is assuming at least partial financial responsibility;

Live in an intermediate care facility, including an intermediate care facility for

people with intellectual disabilities, or a licensed psychiatric hospital;

Receive independent living subsidy payments from the department to assist the

individual in living independently after foster care payments are discontinued;

Is a child for whom an adoption assistance agreement from another state is in

effect, regardless if a payment is being made;

In a state-subsidized adoptive placement, if an adoption assistance agreement is in

effect between a public agency of Oregon and the adoptive parents, indicating title

IV-E or Medicaid eligibility.

A child in substitute care must meet all TANF nonfinancial and financial eligibility

requirements. However, there are no school attendance requirements for SAC.




https://apps.state.or.us/cf1/DHSforms/Forms/Served/HE7210.pdf

https://apps.state.or.us/cf1/DHSforms/Forms/Served/SE0539A.pdf





Children subject to an adoption assistance agreement described above are assumed

eligible for the SAC program.


Specific Requirements; SAC: 461-135-0150


Household group (who is in the household?)

For the SAC program when there is no Child Welfare involvement, if a child has been

referred by a parent or guardian to a PRTS or BRS facility, the facility will apply for the

child as a household of one. The child is still considered to be in the household when

absent for illness. This includes children in PRTS or BRS facilities. (For a child referred

by the family or guardian to a drug or alcohol treatment facility, please see the OHP

medical chapter.)

Household Group: 461-110-0210

Filing group (who must apply together?)

When there is no Child Welfare involvement, the SAC filing group includes only the

child who meets all nonfinancial eligibility requirements.

Filing Group; Overview: 461-110-0310

Filing Group; EXT, MAA, TANF: 461-110-0330

Filing Group; MAF and SAC: 461-110-0340

Filing Group; HKC, OHP: 461-110-0400

Financial group (whose income and resources are counted?)

For SAC when there is no Child Welfare involvement, the financial group is comprised

of the child in the filing group who meets all nonfinancial eligibility requirements.

Financial Group: 461-110-0530

Need group (what income standard is used?)

For SAC when there is no Child Welfare involvement, the need group is comprised of the

child from the financial group who meets all financial eligibility requirements.

Need Group: 461-110-0630













Resource limits and transfers

For SAC, the need group is not eligible for benefits if the financial group has countable

resources equal to or greater than the need group resource limit.

The resource limit for SAC is $2,500.

When a transfer of assets occurs it must be reported at application, redetermination, and

when the transfer occurs.

To qualify for SAC benefits, a member of the financial group must not have made a

disqualifying transfer of their assets within three years preceding the date of request. The

transfer of asset is only disqualifying if the client is an inpatient in a nursing facility or

medical institution in which payment for the client is based on a level of care provided in

a nursing facility.

Making a disqualifying transfer of available assets will result in termination of benefits.

When the client is ineligible for benefits because of a disqualifying transfer of assets, the

client remains ineligible until the disqualification period ends, or when the full equity

rights in the asset are transferred back to the client, or the client receives adequate

compensation.


Asset Transfer; General Information and Timelines: 461-140-0210

Income deductions and exclusions

Exclusions are subtracted prior to the countable income test.

Deductions are subtracted after the client has passed the countable income test.

Instead of allowing the TANF income deductions, use the following deductions and

exclusions:

Child support disregard

Exclude up to $50 per month, per dependent child or minor parent receiving child

support, per financial group. Only allow a disregard for dependent children or

minor parents who are in the financial group;

Disregard includes current child support only;

This exclusion is not to exceed a total of $200 per financial group per month. The

child support disregard is subtracted prior to the countable income test.





Self-employment deductions

Because SAC covers individuals who are below 21 years of age, there may be times

when an individual may be eligible for SAC and their earned income would be counted.

This section provides self-employment income deductions allowed for SAC eligibility.

Determine the amount of a self-employed person's countable earned income by

reducing the amount of their gross sales or receipts by the amount of their

allowable costs of producing the income. See Section B of the Counting Client

Assets (CA-B) chapter for allowed costs.

Once the amount of countable earned income is determined (including countable self-

employment income) allow the following deductions from each person's earned income.

The first $120, plus one-third of the balance of their earned income; and

A dependent care deduction up to $200 for each dependent under age 2, and $175

for each dependent age 2 and over. Costs may be incurred for hours worked, meal

and commuting time, medical leave and work-related training.

Earned Income Deductions and Order Applied; MAF and SAC: 461-160-0190

Unearned Income Exclusion for Child and Spousal Support; MAF and SAC: 461-160-0200

5. Required verification

Verify the following eligibility requirements for SAC:

Social Security Number or an application for a number;

Citizenship. Acceptable evidence of citizenship must be provided for some SAC

recipients;

Alien status for persons who indicate they are not U.S. citizens but say they have

legal immigration status;

American Indian/Alaska Native tribal membership or eligibility for benefits

through an Indian Health Program;

Income and resources for children in substitute care;

Eligibility for adoption assistance for adopted children. The family of a child

receiving adoption assistance from another state should have a letter or a copy of

the Adoption Assistance Agreement from that state which will confirm the child's

eligibility for adoption assistance.


Verification; General: 461-115-0610


http://dhsmanuals.hr.state.or.us/EligManual/10ca-b.htm









The effective date for starting medical benefits for an eligible client is as follows:

In the SAC program when converting from HKC (KCE) subsidy:

When converting an HKC subsidy client (KCE coding) to SAC, begin benefits the

first of the month following the month that KCE eligibility ends;

Enter a Compute action on the UCMS screen for the first of the next month.

Change the medical start date on CMUP to the first of the next month.

In the SAC program when not converting from an HKC (KCE) subsidy:

If the client meets all eligibility requirements on the date of request, begin medical

effective the date of request;

If the client does not meet all eligibility requirements on the date of request, the

effective date is the first day following the date of request that all eligibility

requirements are met within the month of the date of request or the following

month if ineligible the month of the date of request.

When floating the budget month, consider financial and nonfinancial eligibility

requirements for the new budget month when determining eligibility.

SAC retroactive eligibility effective dates

Clients who are eligible for SAC are also potentially eligible for retroactive medical

benefits.

If a benefit group requests and is eligible for retroactive medical benefits, the

earliest date they can be eligible is three months before the date of request. For

example, if the benefit group requests benefits on July 10, eligibility may begin as

early as April 10;

Once the earliest date is established, eligibility is determined on a month-by-month

basis. For example, if the benefit group requests benefits on August 10, the earliest

date is May 10. Eligibility is established separately for May 10 through May 31,

June 1 through June 30, July 1 through July 31, and August 1 through August 9. A

client may be eligible for some or all of the months.

Specific Requirements; Retroactive Medical: 461-135-0875

Effective Dates; Initial Month Medical Benefits: 461-180-0090

Effective Dates; Retroactive Medical Benefits: 461-180-0140


http://apps.state.or.us/caf/arm/B/461-180-0090.htm


FSML – 70B Medical Assistance Programs D –

August 1, 2013 Medical Assistance Assumed D - 1

D. Medical Assistance Assumed (MAA)

The Medical Assistance Assumed program provides medical assistance to low-income

families when children are deprived of parental support because of continued absence,

death, incapacity or unemployment. Eligibility is based in part on TANF program

(formerly Aid to Families with Dependent Children) standards and methodologies

instituted by the Personal Responsibility and Work Opportunity Reconciliation Act of

1996 (PRWORA).


The Application for Oregon Health Plan and Healthy Kids (OHA 7210), Oregon Health

Plan (OHP) Standard Reservation List – OHP Application (OHP 7210R), Oregon Health

Plan Application (online application) (OHP 7210W) or the Application for Services

(MSC 415F) may be used by new applicants.

Medical applicants who are current recipients of any other Department of Human

Services (DHS) or Oregon Health Authority (OHA) Self Sufficiency program are not

required to submit an application at initial application or redetermination. The department

may determine or redetermine medical eligibility without a new application, or by

amending the current application.


To be eligible for MAA, a client must be a dependent child or a caretaker relative of a

dependent child. However, a dependent child or caretaker relative cannot receive MAA

while foster care payments are being made for the child, with one exception. If a child in

foster care is expected to return within 30 days, the caretaker relative may be eligible for

MAA based on the expected return of the child. Confirm the expected return date with

Child Welfare (CW).

A dependent child must be under the age of 18, or 18 and regularly attending high school

or equivalent full time.


Age Requirements for Clients to Receive Benefits: 461-120-0510

Regular School Attendance: 461-120-0530 - Repealed

Caretaker relatives can also receive MAA if their only child is an SSI recipient, if they

are not requesting medical benefits for their child, or their child is ineligible for MAA

only because citizenship has not been documented yet. In each of these cases, there is still

a dependent child in the household.

Either parent whose only child is an unborn child can qualify for MAA if the mother's

pregnancy has reached the calendar month before the month in which the due date falls.






Medical Assistance Programs D – FSML – 70B

D - 2 Medical Assistance Assumed (MAA) August 1, 2013

Either parent of the unborn child can receive MAA even before the mother's pregnancy

has reached the calendar month before the month in which the due date falls if there is

another dependent child in the filing group.

For ongoing MAA/MAF/EXT/OSIPM clients who then become pregnant, add the

pregnancy related coding (DUE and UB coding) without a redetermination.

Note: A redetermination for a current MAA benefit group may be necessary if a

pregnancy now brings the father of the unborn into the filing group. Although the

pregnant woman would have protected eligibility, the rest of the family may no

longer be eligible for MAA.

A minor parent will continue to be eligible for MAA if they lose TANF eligibility

because they refuse to live with a parent or adult relative, or if they go over income due

to deeming when they are required to return to live with a parent for TANF eligibility.

The minor parent must also continue to meet all other MAA eligibility requirements.

People disqualified from TANF only because they have not cooperated with JOBS or

substance abuse/mental health requirements are still eligible for MAA as long as they

continue to meet all other MAA eligibility requirements.

Persons serving a TANF or SNAP intentional program violation (IPV) penalty may still

qualify for MAA, even if not pregnant.


Specific requirements; MAA, MAF, and TANF: 461-135-0070

TANF Eligibility for Minor Parents: 461-135-0080

Deemed Assets, Parents of Minor Parent; MAA, MAF, TANF: 461-145-0860

3. Eligibility groups for MAA


A household consists of people who live in the same house, apartment, or other dwelling.

A dwelling can contain more than one household if it is divided into separate living units,

or if a landlord/tenant relationship exists. To have a valid landlord/tenant relationship, the

landlord must live independently and bill the tenant for rent at fair market value. They

may share bathroom and kitchen facilities, but only in a commercial room and/or board

establishment.

For homeless groups, the household is the people who consider themselves as living

together.

Do not use a legal custody agreement to determine whether a child resides with the

mother or the father. Instead, ask the parent where the child resided during the budget

month. Be specific; you may need to ask questions about the particulars. For example,







ask: Did the child reside with you on the first of the month? Where does the child live

during the week? What days of the week does the child spend the night at your home?

Once you have the answers, determine the number of days the child resided in each

household and calculate the percentage.

A person who leaves the household for short periods is considered to still be in the

household if they intend to return. If they are gone for 30 continuous days or more, they

are no longer in the household unless they must still be included under one of the

following:

A parent is gone because of employment while the other parent remains in the

home. This includes people with jobs that customarily take them away from home,

such as military service, truck driving or commercial fishing, and people looking

for work;

A parent or caretaker relative is gone for a maximum of 90 days when they are

staying in a residential alcohol or drug treatment facility;

A person is receiving treatment in a general hospital and expected to return home.

If they are not expected to return home, they remain in the household until they

enter some other living arrangement, such as a nursing home;

A child is gone for illness, social service or educational reasons. They are no

longer in the household if they are admitted to a Medicaid facility such as a

nursing home or residential treatment facility for more than 30 days;

Children in foster care, if they are expected to return home within the next 30 days.



The filing group is the people from the household group whose circumstances are

considered in the eligibility determination process. The filing group includes people who

must apply together because of their relationship to eligible people.

When a person is in more than one filing group for the same program, the filing groups

must be combined, unless specified otherwise in administrative rule.

For MAA, the filing group must include a parent or caretaker relative and dependent

child or unborn.

People in the household group are included in the MAA filing group because of their

relationship as follows:

Parents of the dependent child;

Parents of an unborn;




Siblings of the dependent child. Siblings must be under 18 years of age or age 18

and attending high school or equivalent full time. (See below for exceptions for

siblings receiving adoption assistance or for siblings who are minor parents.);

Caretaker relatives;

For needy caretaker relatives of the dependent child, their spouse, and their

dependent children.

People in the household group may be excluded from the MAA filing group as follows:

Exclude dependent children who have been or will be receiving foster care

payments for more than 30 days;

A sibling of a dependent child must be excluded from the filing group if the sibling

is receiving adoption assistance;

Allow minor parents to form a separate filing group with their dependent children

when the minor parent lives with an adult relative who is not his or her parent or

the parents of the minor are in the household, but is not applying for MAA for the

minor parent or any of the minor parent's siblings.




The financial group consists of the filing group members whose income and resources

count in determining eligibility and benefits.

For MAA, the financial group includes all the people in the filing group except the

following:

Caretaker relatives (other than parents) who choose not to be included in the need

group. These people are known as non-needy caretaker relatives;

People receiving SSI benefits.

When a minor parent lives with their parent, the income of the parent must be deemed to

the minor parent unless the minor parent has been married or legally emancipated.

Financial Group; Overview: 461-110-0530

Deemed Assets, Parent of Minor Parent; MAA, MAF, TANF: 461-145-0860


The need group consists of the people whose basic and special needs are used in

determining eligibility. The number in the need group determines which income standard

to use.







For MAA, the need group includes financial group members who meet all nonfinancial

eligibility requirements, except that noncitizens do not need to meet the alien status

requirement to be included.

There are some MAA financial group members who cannot be included in the need

group:

Individuals who do not provide a Social Security number or proof they applied;

Parents who are in foster care and receiving foster care payments, and are applying

for their dependent children;

Siblings who do not meet deprivation requirements;

Unborn children.

Need Group: 461-110-0630

CAWEM

Noncitizens who meet all the financial and nonfinancial requirements of MAA except for

their citizenship/alien status are eligible for limited emergency medical assistance. The

policy for forming eligibility determination groups for CAWEM MAA is the same policy

for the MAA program if they did meet the citizenship/alien status requirement.

Specific Requirements; Citizen/Alien-Waived Emergent Medical (CAWEM): 461-135-1070

4. Deprivation for MAA

Determining deprivation for a child

In order to receive MAA or MAF, a dependent child must be deprived of parental support

or care because of absence, death, incapacity, unemployment or underemployment of a

parent.

When a child lives with one parent or does not live with any parent, the basis of

deprivation is the continued absence or death of a parent. When a child lives with both

parents, the basis of deprivation is unemployment, underemployment, or incapacity of a

parent.

Note: Not all children in a MAA or MAF need group will have the same basis of

deprivation.





Deprivation based on death

If either parent of a child is deceased and the other parent has not remarried, or has

remarried but the stepparent is not living in the home, the child meets deprivation based

on death. Deprivation Based on Death: 461-125-0060

Deprivation based on continued absence

Continued absence may exist when the child lives with only one parent or does not live

with any parent and the absent parent has been or is expected to be gone from the

household for at least 30 days. The parent is considered absent when any of the following

is true:

He/she lives in a separate residence and does not visit the child in the child’s home

more than four times or 30 hours per week;

He/she is confined to an institution and the confinement is anticipated to last more

than 30 days;

He/she is living in the child’s home only to serve a court-imposed sentence by

performing unpaid public work and unpaid community service during the

workday;

The dependent child is adopted by a single parent and the parent is not living with

a spouse;

More than one person is identified as the child’s father and legal paternity has not

been established.

The parent is not considered absent when:

The absence is due to the parent’s participation in the uniformed services of the

U.S.;

Both parents, though not living together, make day-to-day decisions about the

child’s life and the child sleeps at least 30 percent of the time during the calendar

month in the home of each parent;

The absence is due to employment, education or training. For example, the parent

is gone while looking for work outside the area of their residence or their

employment, education or training takes them out of their residence.

When parents have shared custody of a child it will be necessary to determine what

percentage of nights the child sleeps in the home of each parent. A worker may need to

ask the client what nights of the week the child sleeps in the home of the absent parent.

Once this information is made available, calculate the percentage by dividing the total

number of nights a month the child sleeps in the home of the absent parent by the number

of days in that month. If the percentage is 30 percent or greater AND both parents make




day-to-day decisions about the child’s life, there is no deprivation based on continued

absence.

Example 1: Sarah and her child Charlie turn in an application requesting

medical benefits, DOR 01/25/12. Sarah indicates that Charlie’s

father, Robert, helps make day-to-day decisions concerning

Charlie. She also indicates that Charlie stays every other weekend,

Friday and Saturday night, at Robert’s house. In January he

stayed with Robert every other weekend starting with the weekend

of January 1. Using a calendar and the information provided, the

worker determines that Charlie slept at Robert’s house five nights

in the month of January. Calculation: 5 nights/31 days in January

= 16%. Even though Robert and Sarah both make day-to-day

decisions about Charlie, Charlie only sleeps 16 percent of the time

during the calendar month in Robert’s home. Deprivation is met

based on continued absence.

Example 2: Dawn and her child Travis request medical benefits. Dawn reports

that she has joint custody of Travis with his father John. Both

parents make day-to-day decisions concerning Travis. Dawn states

that Travis consistently stays with her from after school on

Monday until Friday morning when he leaves for school (four

nights a week). John picks him up from school on Friday, and

Travis stays with him until Monday morning (three nights a week).

Although Travis is in Dawn’s household the majority of the time,

because he sleeps in each parent’s house at least 30 percent of the

time (Calculation: 3 nights/7nights = 42%) and both parents make

day-to-day decisions about Travis, there is no deprivation based

on continued absence for the MAA or MAF programs. Eligibility

for OHP should be considered.

OAR 461-001-0000 defines “parent” as the biological or legal (step or adoptive) mother

or father of an individual or unborn child. This means that the worker may need to

determine that the dependent child is deprived of parental support or care from both a

biological parent and a step-parent for deprivation based on absence to exist.

Example 3: Julia and her husband Rocky are currently separated but

attempting to reconcile. Julia has a child from a previous

relationship, Andy, for whom she is requesting benefits. When

asked about how often Rocky visits her child, Julia explains that

while Rocky does maintain a separate residence, he stays at her

home and spends time with them every weekend from Friday after

work until Monday morning when he leaves for work.

Even though Andy does not see or hear from his biological father,

Rocky is also considered a parent, and visits Andy in his home in




excess of 30 hours per week. Based on this, there is no deprivation

for MAA. Review for OHP eligibility.

Deprivation Based on Continued Absence of a Parent: 461-125-0090

Situations of Deprivation Based on Continued Absence: 461-125-0110

Situations of No Deprivation Based on Continued Absence: 461-125-0120

Evidence of Deprivation Based on Continued Absence; MAA, MAF, TANF: 461-125-0130

Deprivation based on incapacity

Deprivation based on incapacity exists when a child lives with both parents and one

parent is unable to work or has a physical or mental condition that is expected to last at

least 30 days and substantially reduces the parent’s ability to provide adequate care or

support for the child. Deprivation based on incapacity is also considered met when a

child lives with both parents and at least one parent is receiving SSI or SSB/SSDI based

on disability or blindness.

Unless receiving SSI or SSB/SSDI based on disability or blindness, incapacity must be

verified with written medical documentation. The medical documentation must be in

writing and contain all of the following:

A diagnosis in medical terminology, including an explanation of whether the

impairment limits the individual’s ability to perform normal functions, and if so,

how?

A prognosis, including an expected recovery time frame;

Clinical evidence from physical examination, psychiatric evaluation, X-rays or

laboratory procedures. This evidence must include objective findings: i.e., specific

data supporting diagnosis of a condition that causes unemployability or incapacity,

either on a medical or psychiatric basis.

To determine eligibility, the department will accept medical evaluations from medical

and osteopathic doctors, visual evaluations from optometrists, and mental evaluations

from licensed clinical psychologists and psychiatrists. The department will accept

supplemental medical and vocational information from a licensed social worker, licensed

physical or occupational therapist, or licensed nurse practitioner to augment evaluations

from acceptable medical sources.

Deprivation Based on the Incapacity of a Parent: 461-125-0230

If the applicant is unable to provide medical documentation, authorize an administrative

examination payment. The payment must only be for the report from the doctor or for a

medical or psychological evaluation and report.

FOR MORE INFORMATION ABOUT ADMINISTRATIVE EXAMS, PLEASE SEE THE

DMAP WORKER GUIDE.






http://www.oregon.gov/oha/healthplan/tools_staff/DMAP%20Worker%20Guide.pdf



Deprivation based on unemployment or underemployment

Deprivation based on unemployment or underemployment exists when a child lives with

two parents and the household meets the following criteria.

The Primary Wage Earner (PWE) is unemployed or underemployed. The PWE is

the parent who earned the most money in the 24 months before requesting

medical. The PWE is considered unemployed or underemployed if their monthly

earned income is less than the countable income limit for the need group;

The PWE is not participating in a labor dispute;

The PWE is not separated from their most recent employment for any of the

following reasons:

- Discharged or fired for misconduct, felony or theft;

- Voluntary Quit in anticipation of discharge or without good cause.

The following are not considered to be misconduct:

Isolated instances of poor judgment;

Good faith errors;

Unavoidable accidents;

Absences due to illness or other physical or mental disability;

Mere inefficiency resulting from lack of job skills or experience;

Compelling family reasons, when the individual has made the attempt to maintain

the employer-employee relationship.

Note: If an individual’s most recent employment ended because they were unable to

work due to a disability or medical condition documented by a qualified and

appropriate professional, and it is expected to last 30 days or more, consider

deprivation based on incapacity.

Once a parent is determined to be the PWE, their status cannot change while the family

remains continuously eligible for MAA/MAF, unless:

The other parent later provides evidence that they should have been the PWE at

the time of application; or



The parent who is the PWE is out of the household group for at least one full

calendar month. If so, the branch office must redetermine which parent is the

PWE.

Deprivation Based on Unemployment or Underemployment of the Primary Wage Earner (PWE); MAA,

TANF: 461-125-0170

Unemployment or Underemployment of the Principal Wage Earner-(PWE): 461-125-0190

Determining Primary Wage Earner (PWE); MAA, MAF and TANF: 461-125-0150

What is the most recent employment?

The most recent employment is the last job the PWE had prior to the date of request for

medical benefits that meets the two tests below:

1. The job was within the past 60 days from the date of request for medical benefits;

and

2. The PWE was hired to work 100 hours or more per month, and worked or was

scheduled to work at least 100 hours in their final month on the job.

If the PWE does not have a job that meets the two tests above, the family has cleared

deprivation based on under or unemployment.

If the PWE does have a job that meets the two tests above, the reason for separation from

the most recent employment must be determined. Eligibility workers can make a decision

about whether or not an individual has good cause for their most recent job quit without

waiting for a decision from the Employment Department.

Example: Thomas, Maria and their two children are applying for medical

benefits. Maria is determined to be the PWE. Maria’s most recent

employment was at McDonald’s last month (less than 60 days

ago). She was hired to work 90 hours/month and worked 80 hours

her last month at McDonald’s.

Prior to working at McDonald’s, Maria worked at Target. Her

employment with Target ended eight months ago. She worked

120 hours her last month at Target.

Question: What job would be considered as Maria’s most recent

employment for the purposes of determining deprivation?

Answer: McDonald’s is the last job that Maria had but she was

not hired to work 100 hours or more per month and she did not

work at least 100 hours in her final month on the job. Even though

Maria’s job at Target was 100 hours in her final month on the job,

it was not within the 60 days previous to the DOR. Maria has no

job that qualifies as “most recent employment,” and thus the

children meet deprivation based on unemployment.






Jobs that would not be considered under this rule

Work experience, sheltered work, JOBS Plus assignments, and On-the-Job

Training (OJT) which are related to a JOBS case plan;

Volunteer or unpaid employment; and

Temporary or limited duration employment to include but not limited to

Workforce Investment Act (WIA), summer jobs, jobs connected to federal or state

stimulus funding, day labor or on-call jobs, etc.

Note: An individual who is on Family Medical Leave Act (FMLA) from their current job

is considered to still be working. Therefore, the employment separation would not

be a factor because they have not been separated from their job.

Guidance for determining good cause

If the client is separated from their most recent employment, consider whether or not they

have good cause for the separation.

Reasons for good cause include but are not limited to:

Circumstances beyond the control of the applicant such as layoff; employer went

out of business; or natural disaster preventing the individual from going to work;

A teen parent returning to high school or equivalent:

An individual fleeing from, or at risk of, domestic violence;

An individual in the ninth month of pregnancy or in any month of their pregnancy

and is experiencing a medical complication due to pregnancy. Accept the client’s

statement regarding a medical condition unless questionable;

Unable to obtain or maintain appropriate child care;

Court order;

Employer was unable or unwilling to provide needed accommodation;

Unsafe workplace, risk to an individual’s health and well-being;

Employer engages in employment practices that are illegally discriminatory on the

basis of age, sex, race, religious or political belief, marital status, disability, sexual

orientation or ethnic origin;

Entered, or will be entering within the next 30 days, a residential treatment facility;

Recommendation by Child Welfare or other agency; or



A client in the Parents as Scholars (PAS) program who leaves their job to return to

school.

Example: Faduma, who is pregnant, her husband, and their child apply for

medical. Faduma is the PWE and indicates she quit her last job

due to complications with her pregnancy. She was unable to

continue doing the work at her most recent employment and the

employer was unwilling to change her duties and make

accommodations. Faduma indicates she is still having

complications due to her pregnancy.

The eligibility worker determines she had good cause for her most

recent job separation, and also gives her good cause not to pursue

UC. The worker determines deprivation based on under/

unemployment and narrates how this decision was made.

Example: John, his wife Petra and their children apply for medical. John is

the PWE and indicates last week he was terminated from Lowe’s

where he was working 40 hours a week. His job at Lowe’s is the

job considered to meet the most recent employment definition.

John states he was terminated due to attendance issues, was

provided multiple warnings with requirements for improvement,

but did not improve.

The eligibility worker determines that John does not have good

cause for the job separation from Lowe's and determines that no

un/underemployment deprivation exists.

Note: A separate eligibility requirement is pursuing UC. If an otherwise eligible client

has a potential UC claim, consider whether or not they must pursue the UC claim.

If the PWE left their most recent employment to accept another job, we could

consider it good cause only when:

- The offer was definite;

- Work was to begin in the shortest length of time as can be deemed

reasonable under the individual circumstances;

- The offered work must have been reasonably expected to continue; and

- The offered work would have paid an amount greater than the work the

PWE left.

Example: Samuel and Carrie and their child are applying for medical.

Samuel is determined to be the PWE. Samuel was working for

FedEX when he quit two weeks ago to accept employment with

UPS. He worked 120 hours in his last month at FedEx. He was

hired to work at UPS and had a start date to begin one week after



his job with FedEx ended. Samuel was told he would be working

only 90 hours a month but would be making $3.00 more an hour.

Before he could begin working, UPS retracted the job offer due to

the declining economy. He is now unemployed.

FedEX would be considered as Samuel’s most recent employer.

Samuel left FedEx to accept employment at UPS. His job with UPS

met the following conditions: it was a definite offer; his start date

was within a reasonable amount of time from his end date with

FedEx; at the time he accepted the position with UPS it was

reasonably expected he would continue; and he was being paid

more than his work at FedEx. The worker can give good cause for

the FedEx job ending.

If the eligibility worker determines the PWE has good cause for their most recent job

separation and it is later determined the PWE was denied UC, consider good cause for the

UC denial. If the PWE does have good cause, narrate the findings and continue benefits

at the current level. If the PWE does not have good cause look at converting the case to

OHP.

Example: Carl, his wife and children apply for medical. Carl is the PWE and

indicates his most recent employment ended due to a lay off. The

eligibility worker determines deprivation exists and narrates this

decision. A month later a SNAP application is processed for the

family and the eligibility worker views Carl’s ECLM screen. The

screen indicates Carl was denied UC due to theft. The eligibility

worker determines there was no good cause for the most recent job

separation and there is no deprivation. The worker reviews for

OHP using the day this decision was made as the DOR.

Reasons that would not be considered good cause include:

Leaving work rather than paying union membership dues;

Leaving work to attend school, unless required or allowed by law or OAR;

Refusing to join a bona fide labor organization when membership therein was a

condition of employment;

Willful or wantonly negligent failure to maintain a license, certificate or other

similar authority necessary to the performance of the occupation involved, so long

as such failure is attributable to the individual; and

Resignation to avoid what would otherwise be a discharge or potential discharge

for misconduct, theft or felony.



When the PWE is self-employed

A PWE who is self-employed is also affected by these eligibility requirements. First, the

worker will determine if the self-employment job would be considered the PWE’s most

recent employment. The calculation to determine if the client worked at the self-

employment job for at least 100 hours a month is based on the gross income made per

month divided by Oregon minimum wage. If the self-employment job meets the

definition of most recent employment, the worker needs to decide whether or not the

client has good cause for their job ending.

Example: Frank, Sheila and their children are applying for medical benefits.

Frank is determined to be the PWE. He last worked three weeks

ago in his self-employment job. He was selling goods at the

Saturday Market. He earned $600.00 in the final month.

Question: Would Frank’s self-employment job be considered his

most recent employment?

Answer: No. $600/$8.50 (current minimum wage) = 78.6 hours,

which is less than 100 hours. Since Frank does not have a job that

meets the definition of most recent employment, the children meet

deprivation based on unemployment.

Determining deprivation for a child/unborn without legal paternity

If the mother and the alleged father of the dependent child or unborn are living together,

and either the mother or the alleged father claims he is the father, and no other man has

been identified as the father, deprivation for the child is based on two parents in the

household: i.e., incapacity or un/underemployment.

After MAA/MAF benefits have been approved, both parents must cooperate with DCS to

establish paternity. The parent who refuses to cooperate will be disqualified according to

the rule on DCS disqualifications.

Note: Medicaid clients at application or at redetermination have minimal DCS

cooperation requirements. They must complete and sign the application, but

cannot be required to complete paternity affidavits or any additional tasks.

Determining Deprivation for Child/Unborn Without Legal Paternity: 461-125-0050

Change in basis of deprivation

When a change occurs that could affect a child’s deprivation status, initiate a

redetermination using the date the household reported the change as the date of request

(DOR). Give the filing group up to 45 days from the DOR to establish their eligibility

using a different basis of deprivation. If they do not provide documentation by the

45th day and do not have good cause, send a 10-day notice of closure. No DHS 462A is

required. If the case has been BED coded, the CM system will automatically send the





77B BED closure notice. If the MAA N/R date on each individual is prior to the BED

N/R date, the case will close notice automatically.


Budgeting is the process of determining whether a person meets all the nonfinancial and

financial eligibility requirements in a calendar (budget) month.

Prospective budgeting: For MAA in the Change Reporting System (CRS), use actual

anticipated income in the initial month. Actual anticipated income is the income already

received in the initial month plus all the income that is reasonably expected to be

received within the initial month. To arrive at the anticipated income, the client and the

worker jointly determine the anticipated income to be counted. Workers will count only

income that is reasonably certain to be available. Do not convert, annualize, or average

income for new applicants or when adding a new applicant to an existing

MAA/MAF/SAC filing group.

There is no overpayment based on incorrectly anticipated information unless the client

withheld information or provided false information.

For ongoing months, income is budgeted prospectively so that anticipated income is the

same for each month. Convert, average, annualize or otherwise budget the income so

that it is the same for each month.

Example: Joe and his two children apply for medical in April. Joe is self-

employed and his last year’s income is representative of his

current self-employment income. In April, Joe expects his income

to be $450. Initial eligibility for MAA is determined by using the

$450 actual anticipated income from the budget month, April.

For May, determine prospective income for ongoing medical

assistance. Use Joe’s gross self-employment history from last year

and divide by 12 to annualize his income. If the annualized income

exceeds the MAA income limit, consider MAF situation #5. If still

over the income limit convert Joe and his children to EXT effective

May 1.

Budgeting using the OHA 945 medical pend notice

The Medical Notice: It’s time to renew your medical benefits (OHA 945) is a medical

pend notice mailed to SSP medical program clients. The OHA 945 establishes a date of

request (DOR) for medical and is used for SSP medical program redeterminations only.

For MAA, the initial budget month is the date of request (DOR) month. For ongoing

months, MAA uses prospective budgeting and unlike OHP and HKC, is not certified. It is

a requirement to act on reported changes at any time during the MAA eligibility period,

including changes reported on the OHA 945.

https://apps.state.or.us/cf1/DHSforms/Forms/Served/DE0945.pdf






Example 1: A client reports an increase in income in the DOR month that

makes the family over income for MAA. Acting on the change

reported for the DOR budget month, redetermine eligibility,

converting to EXT, OHP or another program if necessary.

Example 2: A client reports a child has returned to the MAA filing group in the

DOR month. Redetermine eligibility for the filing group using the

DOR month as the budget month. If eligible for MAA, begin the

child’s medical on the DOR.

For MAA, the DOR month is reviewed and the worker determines whether or not there

are changes being reported that require using the DOR month as the budget month. If not,

use the next month (the last month of the 12-month MAA eligibility period) as the budget

month and redetermine eligibility.

Example 1: The client reports a child has moved back to the household in the

DOR month. Redetermine eligibility using the DOR month as the

budget month.

Example 2: Client and her two children are receiving MAA, eligibility period

ending 06/30/11. The OHA 945 is mailed and a DOR of 05/15/11

is established. The client is not reporting any changes that would

otherwise trigger a redetermination in May. The budget month,

June, is then used to redetermine eligibility (June is the last month

of the current MAA eligibility period).

Example 3: Susie and her son are on OHP. She submits her OHA 945 with a

DOR of 9/15, for an OHP eligibility period that ends 10/31. On the

OHA 945, she requests medical for her daughter, who just moved

back in with her. The family is now under the MAA income limits.

Determine eligibility for the family based on the DOR 9/15, budget

month of September, using actual income. Once MAA eligibility is

determined, open everyone in the filing on MAA, effective

September 15.

Converting, averaging and annualizing

Converting Stable Income: For stable income received once a month, the monthly

amount is used to anticipate what the group's income will be for each month.

For stable income received once a week, convert it to a monthly amount by

multiplying it by 4.3;

For stable income received once every other week, convert it to a monthly amount

by multiplying it by 2.15;






For stable income received on established dates (for example, the 5th

and 20th

of

each month), convert it to a monthly amount by multiplying it by the number of

pay days in each month (in this example, 2).

Example: Mom and child in filing group; mom is receiving OPU and child is

currently receiving OPC. An OHA 945 is submitted; both mom and

child are requesting benefits, mom was working at local motel and

received her final check in budget month of $150.00 and two UC

checks of $100.00 each. For MAA eligibility the budget month is

considered an ongoing month for prospective budgeting. Because

the earned income has ended and is not anticipated to continue,

count actual earned income received in the budget month. UC is

anticipated to continue and is considered stable income and so it is

converted to a monthly anticipated amount by multiplying the

gross weekly amount by 4.3. The MAA countable income for the

budget month is: $150 earned income + $430 UC ($100 x 4.3) =

$580.00.

Averaging variable income: For ongoing months of MAA, the worker must determine

what the prospective income will be. In all cases, narrate the way prospective income was

determined. To arrive at the average amount for prospective budgeting, first convert to a

monthly income amount:

For variable earned income based on an hourly wage when the past is

representative of future expected income, monthly income is determined by

calculating an average number of hours per pay period, then these hours are

multiplied by the hourly wage and converted to a monthly amount under

section (1) of this rule;

For variable earned income involving various rates of pay (overtime, shift

differential, tips) when the past is representative of future expected income,

monthly income is determined by calculating the average income per pay period,

then the average income is converted to a monthly amount under section (1) of this

rule;

For variable earned or unearned income when the past is representative of future

expected income, and income cannot be calculated using the above guidance,

monthly income is determined by averaging the income using:

- A representative period of months by totaling the income for those months

and dividing by the number of months used; or

- A representative number of pay periods and converting to a monthly

amount under section (1) of this rule.

For variable earned and unearned income when the past is not representative of the

income the financial group will receive during the eligibility period, the client and

the department jointly determine the anticipated income.




Annualizing income: For all medical but OHP, HKC and REFM, when a full year’s

income is received in less than a 12-month period (such as school employees and contract

employees earned income), the income must be annualized to determine what the

prospective income will be. To annualize income (other than self-employment income),

add the income from a 12-month period and divide by 12. The resulting figure is the

annualized income. If past income is not representative of expected future income, use

anticipated income.

Contract income that is not intended to be a full year’s income, and is not paid on hourly

or piecework basis, is prorated over the period of time the income is intended to cover.

Note: Income received on an hourly or piecework basis or monthly over the term of the

contract period it is not annualized. It is treated as stable income.

Annualize self-employment income when it is received during less than a 12-month

period but is intended as a full year's income. Also annualize self-employment income

when the business has operated for a full year and the previous year is representative of

the income and costs expected during the budget month.

Use the gross income on the most recent state and federal income tax forms if available

and there will be no substantial increase or decrease in the next year’s self-employment

income. If a substantial change is expected or there is no tax form available, accept the

estimates of next year's anticipated income. Divide the income - reported or anticipated -

by 12 to arrive at the income for each month.

Example 4: Macy and her two children apply for medical assistance on

July 15. Macy is a teacher’s assistant and her yearly income is

paid over nine months while she teaches. In the summer months,

she is not paid. Macy and her children are found eligible for initial

MAA based on zero income in July, using actual anticipated

income for the budget month.

Macy and her worker talk about her prospective income to assign

to the following month, August. Prospective income for Macy is

determined by averaging the previous year’s income. Using

prospective income methods, Macy and her children are eligible

for EXT effective August 1.

Note: If Macy reports zero income in the following summer months when she

was not working for the school, she is not a new applicant and there has

been no break in medical benefits, and she would have her eligibility

determined using prospective eligibility (not actual anticipated income).

She would not be eligible for MAA at that time. Macy and her child would

be able to continue on her EXT until the end of the 12-month eligibility

period and then could potentially be eligible for OHP.

SEE COUNTING CLIENT ASSETS, SECTION C (CA-C) FOR MORE INFORMATION

ON SELF-EMPLOYMENT INCOME, INCLUDING MICROENTERPRISE INCOME.

http://apps.state.or.us/caf/fsm/10ca-c.htm



Minor parents living with their parents

When a minor parent has formed a separate filing group from their parents, deem the

parents' income as follows:

Allow the $90 earned income deduction;

Deduct the needs of the parents and their dependents, living in the same household

and not included in the benefit group, using the TANF payment standard;

Deduct amounts paid to legal dependents not living in the household;

Deduct payments of alimony or child support;

Any remaining income is countable deemed income;

Exclude the resources of the parents of the minor parent.

There are times when a minor parent must return home to live with his/her parents in

order to be eligible for TANF. In those cases, if the parent’s deemed income is over the

TANF payment standard, the minor parent can still be eligible for MAA if the minor

parent attends high school or its equivalent full-time, or participates in JOBS or another

training program to develop employment or self-sufficiency skills.

Prospective Eligibility and Budgeting: 461-150-0020

Prospective or Retrospective Eligibility and Budgeting; ERDC, MAA, MAF, REF, REFM, SNAP, TANF:

461-150-0060

Prospective Budgeting of Stable Income: 461-150-0070

Prospective Budgeting of Variable Income; Not OHP; Not MRS: 461-150-0080

Prospective Budgeting: Annualizing and Prorating Contracted or Self-employment Income: 461-150-0090

Resources limits and transfers

Resource limits: For MAA, the need group is not eligible for benefits if the financial

group has countable resources equal to or greater than the need group resource limit.

The resource limit for MAA is $2,500. However, an MAA need group that includes a

Pre-TANF Program participant or TANF recipient who is progressing in a JOBS plan has

a resource limit of $10,000. If at any time a Pre-TANF Program participant or a TANF

recipient no longer cooperates with their case plan, the resource limit is then reduced

back to $2,500.

Asset transfer: To qualify for MAA benefits, a member of the financial group must not

have made a disqualifying transfer of their assets within the preceding three years if they

are an inpatient in a nursing facility or an inpatient in a medical institution in which

payment for the client is based on a level of care provided in a nursing facility. Any

potentially disqualifying transfer of assets must be reported at application,

redetermination, and when the transfer occurs. A disqualifying transfer of assets during

the preceding three years or during the eligibility period for the purpose of establishing or








maintaining eligibility for benefits will result in termination and/or disqualification of

benefits for the filing group.


client remains ineligible until the disqualification period ends, when the full equity rights

of the asset are transferred back to the client, or when the client receives adequate

compensation.



Resource Limits: 461-160-0015



Deductions are subtracted after the client has passed the countable income test:

Child support disregard:

For MAA applicants and recipients, exclude up to $50 per dependent child or

minor parent receiving child support, per financial group;

This exclusion is not to exceed a total of $200 per financial group per month. The

child support disregard is subtracted prior to the countable income test.

SEE CHILD SUPPORT CHAPTER H (CS-H) FOR MORE INFORMATION ABOUT THE

CHILD SUPPORT PASS-THROUGH AND DISREGARD, INCLUDING EXAMPLES.

Earned income deduction: MAA clients who are not in the microenterprise component

of JOBS receive one income deduction; the earned income deduction. All individuals in

the financial group with earned income are allowed a deduction of 50 percent of

their gross earned income. This includes all self-employment income. Clients are

eligible for the deduction as long as they have earned income in the budget month. MAA

applicants must first pass the countable earned income test to be eligible for the earned

income deduction.

For individuals in the MAA financial group who are in the microenterprise component of

the JOBS program and who have earned income from a microenterprise, business

expenses are deducted from the business’s gross receipts. This is done according to

general accounting principles and OAR 461-145-0920 by an accounting professional

such as a certified public accountant or bookkeeper. The remainder is the individual's

countable income.

Compare the microenterprise income, together with the financial group's other countable

income, to the Countable Income Standard. If the income is at or over the standard, the




http://dhsmanuals.hr.state.or.us/EligManual/09cs-h.htm




group is ineligible. If it is under the standard, apply the 50 percent earned income

deduction to the microenterprise income and other countable earned income.

Child Support and Cash Medical Support: 461-145-0080

Earned Income Tax Credit (EITC) and Making Work Pay (MWP) Tax Credit: 461-145-0140

Self-Employment; Costs That Are Excluded To Determine Countable Income: 461-145-0920

Self-Employment; Determination of Countable Income: 461-145-0930

Dependent Care Costs; Deduction and Coverage: 461-160-0040

Earned Income Deduction; MAA, REF, TANF: 461-160-0160

MAA income standards

Countable income limit: This is the amount of countable income remaining after

allowable exclusions.

Adjusted income/payment standard: This is countable income minus deductions.

Number in

Need

Group

Adjusted

Income

Countable

Income

1 $326 $345

2 416 499

3 485 616

4 595 795

5 695 932

6 796 1,060

7 886 1,206

8 976 1,345

9 1,039 1,450

10 1,150 1,622

+1 +110 +172

Income and Payment Standards; JOBS, MAA, MAF, REF, SAC, TANF: 461-155-0030

How Income Affects Eligibility and Benefits; MAA, MAF, REF, SAC, SFPSS, TANF: 461-160-0100

MAA Asset Quick Reference Chart: Download the MAA Asset Quick Reference

Chart in PDF format.











http://dhsmanuals.hr.state.or.us/EligManual/PDF/08ma-fchart.pdf

http://dhsmanuals.hr.state.or.us/EligManual/PDF/08ma-fchart.pdf



In the MAA program, when converting from HKC (KCE) subsidy:

When converting to MAA from MAF, OHP, CHIP or SAC, if the client meets all

eligibility requirements on the date of request, begin MAA medical effective the

DOR;

If the client does not meet all eligibility requirements on the DOR, the MAA

effective date is the first day following the DOR that all eligibility requirements

are met within the month of the date of request, or the following month if

ineligible the month of the date of request;



Example: Mary establishes a DOR on June 12, requesting medical assistance

for her child and herself. Using June as the initial budget month,

they meet all eligibility requirements for MAA except for being

over the resource limit. Mary has $3,000 in savings that she will be

using to buy a car with in July.

On July 10 Mary purchases the car using $2,900 of the savings.

She is now below the resource limit. The worker floats the budget

month to July, asks for Mary’s income for July and redetermines

MAA eligibility using July as the budget month. They are now

eligible for MAA. The worker opens MAA for Mary and her child

with a start date of July 10, the day they met all of the MAA

eligibility requirements.

Coding:

C/D MAA

N/R MAA 0711

MAA retroactive eligibility effective dates

Clients who are eligible for MAA are also potentially eligible for retroactive medical

benefits.



example, if the benefit group requests benefits on July 10, eligibility may begin as

early as April 10;

After the earliest date is established, eligibility is determined on a month-by-month

basis. For example, if the benefit group requests benefits on August 10, the earliest

date is May 10. Eligibility is established separately for May 10 through May 31,

June 1 through June 30, July 1 through July 31, and August 1 through August 9.



Example: Mallory is applying for medical benefits for herself and her two

children with a DOR of 08/10/10, and is determined eligible for

MAA. She reports that in the last week of May, she was seen while

she was uninsured at an urgent care clinic, with no other medical

services received since then. The worker reviews income and other

eligibility criteria for May, and determines that she is eligible for

retroactive medical. The worker then sends a MSC 148 to

Maintenance, Client to provide medical coverage for Mallory for

05/10/10 (earliest eligibility date) – 05/31/10 and codes a

case/descriptor of “RM” on Mallory.

Example: Douglas is a single father of one child, Chester. Douglas had

employee-sponsored health insurance for himself and Chester up

until five months ago when he lost his job. Chester has an ongoing

medical condition for which he sees a specialist monthly.

Now, Douglas is requesting medical benefits with a DOR of

06/11/1,1 and reports that he has incurred ongoing medical

expenses since his insurance ended five months ago, though

Chester has not been to the doctor yet in June. The worker reviews

the three months prior to the DOR (03/11/11-06/10/11) and finds

that all MAA eligibility criteria is met for each of the months. Since

there was no medical expense incurred in June, the worker sends a

MSC 148 to CMU to provide coverage for 03/11/11-05/31/11 and

codes a case/descriptor of “RM” on Chester. Their eligibility

period will begin on 06/11/11.




Non-CAWEM MAA children may qualify for Continuous Eligibility for Medicaid

(CEM) if they lose eligibility for MAA prior to their next scheduled 12-month

redetermination.








This page intentionally left bPlank.

FSML – 70B Medical Assistance Programs E –

August 1, 2013 Medical Assistance to Families (MAF) E - 1

E. Medical Assistance to Families (MAF)

The Medical Assistance to Families program provides medical assistance to people who

are ineligible for MAA but are eligible for Medicaid using TANF (previously AFDC)

program standards and methodologies that were in effect as of July 16, 1996.


The Application for Oregon Health Plan and Healthy Kids (OHA 7210), Oregon Health

Plan (OHP) Standard Reservation List – OHP Application (OHA 7210R), Oregon

Health Plan Application (online application) (OHA 7210W) or the Application for

Services (MSC 415F) may be used.

A new application may not be needed if the child is transitioning from another medical

program or has joined a household currently receiving medical assistance or another

program benefit such as SNAP.

2. Specific program requirements for MAF

When a family or child becomes ineligible for or is denied MAA because of their

household composition or income, determine eligibility for MAF medical assistance prior

to converting to EXT or other OHP Plus medical program.

To be eligible for MAF, a client must be a dependent child or a caretaker relative of a

dependent child. However, a dependent child or caretaker relative cannot receive MAF

while foster care payments are being made for the child.

A dependent child must be under the age of 18, or 18 and regularly attending school full

time.



Regular School Attendance: 461-120-0530 - Repealed

Family members may be eligible for MAF when ineligible for MAA under the following

situations:

Situation 1: If a blended (yours/mine/ours) family is ineligible for MAA because

of income, resources or other program requirements, eligibility may exist by

forming separate filing groups under MAF.

For MAF, a blended family is one in which there is at least one child or unborn in

common and the parents are unmarried. To fit in situation 1, there must also be at

least one other child in the household from a prior relationship. If the only child is

an unborn child in common, it is a situation 2 family (see below);






Medical Assistance Programs E – FSML – 70B

E - 2 Medical Assistance to Families August 1, 2013

Situation 2: This situation is for a mother, father and their unborn child; there are

no other children of these parents in the household, and the family is over income

for MAA because of income from the father of the unborn child. If the father of

the unborn child is not married to the mother and there are no other dependent

children, the mother and the unborn child form a separate filing group. Deem the

father's income to the mother (use the Medical Assistance to Families (MAF)

Deeming Form (OHA 420A). (If the father of the unborn is also the father of

another child in the household, consider situation 1.)

Note: Do not begin MAF benefits until the calendar month before the month in

which the due date falls. For both MAA and MAF, if the only child is an

unborn child, there is no MAF eligibility for the pregnant woman until the

month before the calendar month in which the due date falls.

Situation 3: A family is over income for MAA because of income from an

ineligible noncitizen(s). The ineligible noncitizen(s) with income drops out of the

filing group. Eligibility for MAF may exist by deeming (use the OHA 420A) the

noncitizen(s) income to the MAF financial group.

When deeming the noncitizen's income, deduct the adjusted income limit amount

for the number of ineligible noncitizens who fall out of the filing group. The

family may choose not to apply for MAF benefits for one or more ineligible

noncitizens who have income. If the family so chooses, deduct the adjusted income

limit amount for as many ineligible noncitizens with income who drop out of the

filing group to make the balance of the filing group eligible for MAF benefits.

For example, if there is an adult noncitizen and two noncitizen children who do not

meet the alien status requirements but only the adult has income, you may choose

to deduct the adjusted income limit for the adult only. The two noncitizen children

may receive MAF CWM.

In families with more than one ineligible noncitizen with income, it is possible to

remove only one of the ineligible noncitizens from the filing group. For example,

in a family with an ineligible noncitizen mother and an ineligible noncitizen father

and one citizen child, if the father’s income puts the need group over the MAA

income standard, the father can be removed from the MAF filing group and his

income deemed to the financial group, making the mother MAF CWM and the

child MAF. Or, if more advantageous to the family, the mother and father can both

be removed, and income from both parents deemed to the child if removing both

parents will make the child MAF eligible.

Situation 4: A family is over income for MAA because of income from the spouse

of a needy caretaker relative (the caretaker relative is not a parent). For MAF, the

spouse with income is removed from the filing group of the needy caretaker

relative and the dependent child. If the spouse has any dependent children not in

common with the needy caretaker relative, they must be removed also. Deem the

spouse's income to the MAF financial group (use the OHA 420A).

https://apps.state.or.us/cf1/DHSforms/Forms/Served/de0420a.pdf





Situation 5: A family with self-employment income is over income for MAA.

Eligibility for MAF may exist by deducting allowable costs of producing self-

employment income.



Specific Requirements; MAA, MAF, and TANF: 461-135-0070





such as an apartment house, or if a landlord/tenant relationship exists. To have a valid

landlord/tenant relationship, the landlord must live independently and bill the tenant for

rent at fair market value. They may share bathroom and kitchen facilities, but only in a

commercial room and/or board establishment.

For homeless groups, the household is the people who consider themselves as living

together.

When people live in more than one household during a month, they are considered to be

living in the household where they spend 51 percent or more of their time.





during the week?






following:

A parent gone because of employment while the other parent remains in the home.

This includes people with jobs that customarily take them away from home, such

as military service, truck driving or commercial fishing, and people looking for

work;

A parent or caretaker relative for a maximum of 90 days when they are staying in a

residential alcohol or drug treatment facility;









A child gone for illness, social service, or educational reasons. They are no longer

in the household if they are admitted to a Medicaid facility such as a nursing home

or residential treatment facility for more than 30 days;







When a household group member is in more than one filing group for the same program,

the filing groups must be combined, unless specified otherwise in administrative rule.

For MAF, the filing group must include a dependent child or unborn.

People in the household group are included in the MAF filing group because of their



Each parent of an unborn child, as follows:

- The mother of an unborn;

- The father of an unborn if there is a dependent child in the filing group or if

he is married to the mother of the unborn.

Siblings of the dependent child if the siblings meet the following nonfinancial

eligibility requirements:

- Age - Under 18 years of age or age 18 and attending school full time;

- Living with a caretaker relative - The caretaker must be one of the

following relatives to the sibling:

(a) Any blood relative, including those of half-blood, and including

first cousins, nephew, or nieces, and person of preceding

generations as denoted by prefixes of grand, great-, or great-great;

(b) Stepfather, stepmother, stepbrother, or stepsister;




(c) A person who legally adopts the child and any person related to the

person adopting the child, either naturally or through adoption.

- Citizen/Alien Status - The sibling must be a citizen of the U.S.; or be a

citizen of Puerto Rico, Guam, the Virgin Islands or Saipan, Tinian, Rota or

Pagan of the Northern Mariana Islands; or be a national from American

Samoa or Swains Islands; or meet the alien status requirements for MAF;

- Deprivation - The sibling must meet a deprivation requirement of the MAA

program.

Needy caretaker relatives of the dependent child, their spouse and their dependent

children.

People in the household group may be excluded from the MAF filing group as follows:

In a two-parent household with common and uncommon children where the

parents are not married, each parent may form their own filing group with their

uncommon children;

A father of the unborn may be excluded from the MAF filing group if there are no

other eligible dependent children in the filing group and he is not legally married

to the mother of the unborn;

One or more ineligible noncitizens with income may be excluded from the MAF

filing group;

The spouse and any dependent children of a needy caretaker relative may be

excluded from the MAF filing group;

Exclude dependent children who have been or will be receiving foster care

payments for more than 30 days;

A sibling of a dependent child may be excluded for the filing group if the sibling is

receiving adoption assistance and counting the sibling's income reduces the filing

group's benefits;

A dependent child is not included in the filing group if the dependent child is or

will be receiving foster care payments for more than 30 days;




The financial group is the filing group members whose income and resources count in

determining eligibility and benefits.





For MAF, the financial group includes all the people in the filing group except people

receiving SSI benefits.





to use.

For MAF, the need group includes all financial group members who meet all

nonfinancial eligibility requirements except for the following:

Parents who are in foster care and for whom foster care payments are being made;

An unborn child.

Need Group: 461-110-0630

Benefit group (who receives benefits?)

The benefit group is those people who receive benefits.

For MAF, the benefit group includes all the need group members if the group meets the

financial requirements.

Benefit Group: 461-110-0750

CAWEM

Noncitizens who meet all the financial and nonfinancial requirements of another medical

program (except OHP-CHP), except for their citizenship/alien status, are eligible for

limited emergency medical assistance. The policy for forming eligibility determination

groups for CAWEM is the same policy for the program the person would qualify for if

they did meet the citizenship/alien status requirement.


4. Verification

Verify the following eligibility requirements for MAF:

Social Security number or an application for a number;

Citizenship. Acceptable evidence of citizenship must be provided for most MAF

recipients who indicate they are U.S. citizens;









SEE SECTION A.1 (NC-A.1) OF THE NONCITIZENS CHAPTER FOR MORE

INFORMATION ON VERIFICATION OF ALIEN STATUS.



Incapacity for deprivation based on incapacity. Other deprivation requirements as

needed.

When an Application Must Be Filed: 461-115-0050



5. Budgeting

For MAF, the initial budget month is the date of request (DOR) month. For the initial

budget month, MAF uses actual income (that already received and what is anticipated to

be received for the remainder of the budget month). For ongoing eligibility, MAF uses

prospective budgeting and like MAA, is not certified. The eligibility worker is required to

act on reported changes at any time during the MAF eligibility period, including changes

reported on the OHA 945.

In all SSP medical programs, when acting on reported changes, the day the change is

reported is considered a DOR; treat the DOR month as the initial budget month when

considering a different program.

Example: A client reports a child has returned to the MAF filing group.

Redetermine eligibility for the entire filing group using the month

the change was reported as the budget month.

If not eligible using the initial budget month for the child’s medical

eligibility, use any floating budget month that falls within 45 days

from the DOR.

Budgeting using the OHA 945

The Medical Notice: It’s time to renew your medical benefits (OHA 945) medical pend

notice is mailed to SSP medical program clients. The OHA 945 establishes a DOR for

medical and is used for SSP medical program redeterminations only.


OHP-OPU; Effective Dates for the Program: 461-135-1102

http://dhsmanuals.hr.state.or.us/EligManual/15nc-a.htm#AlienStat












6. Financial eligibility for MAF

Deeming

For MAF situations 2, 3 and 4, income from the individual excluded from the filing

group must be deemed back to the MAF financial group.

The amount of income to deem back to the financial group if a person is excluded from

the filing group for situations 2 and 3 is determined by deducting from that person’s

nonexcluded income:

The adjusted income standard in OAR 461-155-0030(2) for one person; and

The first $90 of earned income.

These steps would be taken for each person whose income must be deemed to the MAF

financial group. Deemed income is considered unearned income for the financial group.

The amount of income to deem from the spouse of a needy caretaker relative to the MAF

need group for situation 4 is as follows:

Deduct the following from the spouse’s countable income:

- The needs of the spouse and their dependents living in the household, who

are not in the benefit group, at the adjusted income standard; and

- The $90 earned income deduction.

Count any remaining income as unearned income to the financial group.

Deemed Assets, Spouse of Nonparent Caretaker Relative; MAF: 461-145-0870

Deemed Assets; Ineligible Non-Citizens and Father of an Unborn; MAF: 461-160-0120


Deductions are subtracted after the client has passed the countable income test.


Instead of allowing the TANF income deductions, use the following deductions and

exclusions:

Exclude up to $50 of child support per dependent child or minor parent per

financial group per month but not to exceed $200 per financial group per month. A

filing group is only eligible for a $50 disregard of child support for the children

who are receiving child support in the filing group. If only one child is receiving

child support, other children in the filing group would not get the $50 disregard.

The child support disregard is subtracted prior to the countable income test;






Note: See CS-H for more information about the child support pass-through and

disregard, including examples.

For MAF situation 5, determine the amount of a self-employed person's countable

earned income by reducing the amount of their gross sales or receipts by the

amount of their costs of producing the income. See Section B of the Counting

Client Assets chapter (CA-B) for allowed costs;

Once the amount of countable earned income is determined for any of the MAF

situation financial groups (including countable self-employment income) allow the

following deductions from each person's earned income:

- The first $120, plus one-third of the balance of their earned income; and

- A dependent care deduction up to $200 for each dependent under age 2,

and $175 for each dependent age 2 and over. Costs may be incurred for

hours worked, meal and commuting time, medical leave and work-related

training.



MAF income standards

Countable income limit - This is the amount of countable income remaining after

allowable exclusions.

Adjusted income/payment standard - This is countable income minus deductions.

Number in

Need

Group

Adjusted

Income

Countable

Income

1 $326 $345

2 416 499

3 485 616

4 595 795

5 695 932

6 796 1,060

7 886 1,206

8 976 1,345

9 1,039 1,450

10 1,150 1,622

http://dhsmanuals.hr.state.or.us/EligManual/09cs-h.htm

http://dhsmanuals.hr.state.or.us/EligManual/10ca-b.htm





+1 +110 +172

Income and Payment Standards; JOBS, MAA, MAF, REF, SAC, TANF: 461-155-0030

How Income Affects Eligibility and Benefits; MAA, MAF, REF, SAC, SFPSS, TANF: 461-160-0100

Resource limits and transfers

For MAF the need group is not eligible for benefits if the financial group has countable

resources equal to or greater than the need group resource limit.

The resource limit for MAF is:

$10,000 for a MAF need group with at least one JOBS participant who is

progressing in a case plan;

$10,000 for a MAF need group with at least one member who is working under a

JOBS Plus agreement;

$2,500 for all other MAF need groups.

To qualify for MAF benefits, a filing group must not have made a disqualifying transfer

of their assets within the preceding three years. They must report any potentially

disqualifying transfer at application, redetermination and when the transfer occurs.

Making a disqualifying transfer of available assets will result in termination of benefits.


client remains ineligible until the disqualification period ends or when the full equity

rights in the asset are transferred back to the client or the client receives adequate

compensation.

Note: A transfer of asset is only disqualifying if the client is an inpatient in a nursing

facility or medical institution in which payment for the client is based on a level of

care provided in a nursing facility.



Resource Limits: 461-160-0015



In the MAF program when converting from HKC subsidy:

When converting an HKC subsidy client (KCE coding) to MAF, begin benefits the

first of the month following the month that KCE eligibility ends. Enter a Compute

action on the UCMS screen for the first of the next month. Change the medical

start date on CMUP to the first of the next month.








In the MAF program when not converting from an HKC (KCE) subsidy):

Unless converting from an HKC subsidy (see above), if the client meets all

eligibility requirements on the date of request, begin medical effective the date of

request;

If the client does not meet all eligibility requirements on the date of request, it is

the first day following the date of request that all eligibility requirements are met

within the month of the date of request or the following month if ineligible the

month of the date of request;



Retroactive eligibility effective dates



example, if the benefit group requests benefits on July 10 and is found eligible for

MAF, retro eligibility may also be considered for as far back as April 10;

After the earliest date is established, eligibility is determined on a month-by-month

basis. The period starts on the earliest established date and ends on the date the

benefit group requests benefits. For example, if the benefit group requests benefits

on August 10, the earliest date is May 10. Eligibility is established separately for

May 10 through May 31, June 1 through June 30, July 1 through July 31, and

August 1 through August 9.




If the applicant is not eligible for MAF, review for EXT or OHP eligibility.

Non-CAWEM MAF children may qualify for Continuous Eligibility for Medicaid if they

lose eligibility for MAF prior to their next scheduled 12-month redetermination.






FSML – 67 Medical Assistance Programs F –

October 1, 2012 Extended Medical Assistance (EXT) F - 1

F. Extended Medical Assistance (EXT)

The Extended Medical Assistance program provides medical assistance for a period of

time after a family loses their eligibility for MAA or MAF due to an increase in their

child support or earned income.

Non-CAWEM EXT children may qualify for Continuous Eligibility for Medicaid if they

lose eligibility for EXT. (For example, they move out of the parent’s or caretaker

relative’s home, or their EXT coverage was only for four months because their EXT was

based on an increase in child support.)

1. Application process for EXT

An application is not needed for EXT medical assistance.

2. Specific program requirements for EXT

Family members who are eligible for and receiving MAA or MAF may qualify for a

period of EXT medical after their eligibility for MAA/MAF ends.

Persons must have been members of the MAA/MAF benefit group when those benefits

ended to be eligible for EXT.

To be eligible for EXT, at least one member of the filing group must:

Have been eligible for and receiving MAA/MAF in the budget month and then

become ineligible due to an increase in the caretaker relative’s earned income; or

Have been eligible for and receiving MAA/MAF for three of the prior six months

and then become ineligible due to an increase in child support.

Example: Sally and her son Seth were receiving MAA until Sally received a

promotion which put her over the MAA income limit. They are now

receiving EXT for one year. Sally's 17-year-old daughter, Barbara,

joins the household while the family is receiving EXT benefits.

Barbara is included in the EXT filing, financial and need group,

but is not included in the EXT benefit group because she was not in

the MAA benefit group when those benefits ended. If Sally has

requested medical for Barbara, consider OHP.

Example: Allison's MAA medical closed because she did not complete her

redetermination. When she reapplied two months later for MAA for

herself and her daughter Janie, she was over income for MAA

because of an increase in child support.

Medical Assistance Programs F – FSML – 67

F - 2 Extended Medical Assistance (EXT) October 1, 2012

Allison and Janie are not eligible for EXT. They received MAA for

three of the previous six months, but she was not receiving MAA

when she went over the MAA income limit due to the increase in

child support.

The filing group must include a dependent child. A filing group is no longer eligible for

EXT if it does not include a dependent child, but may regain EXT eligibility if it again

includes a dependent child.



Regular School Attendance: 461-120-0530

When an MAA/MAF filing group may be eligible for EXT

The filing group must have become ineligible for MAA/MAF because of an increase in

the caretaker relative's earned income or because of child support received. Do not

require verification of the increased earnings or support.

If another change occurs in conjunction with the increase in the caretaker relative's

earned income or in child support received, the filing group is not eligible for EXT if the

other change, by itself, would have made the filing group ineligible for MAA/MAF.

Example: Anita and her two children, William and Sara, are receiving MAA

when Robert, Anita’s husband, returns to the household. His

earned income puts the family over the income limit for MAA.

The MAA filing group is not eligible for EXT. It was not an

increase of earnings from a caretaker relative in the original MAA

filing group that caused the family to become ineligible for MAA.

While Robert is a caretaker relative, he was not eligible for and

receiving MAA, and it was the earnings he already had when he

joined the MAA filing group that made the filing group ineligible.

Example: Mona and her child live with her partner Sam and his child. They

are two separate filing groups. Sam and his child are on MAA with

zero income; Mona and her child are on EXT with monthly income

of $1,000.

On November 20, Sam reports that he now has a job and

anticipates income of $900 in the month of November, and also

provides proof of pregnancy for Mona as they are now expecting a

child.

She and Sam and their children are now all in the MAA filing and

financial group. Since her income alone puts Sam and his child

over the income limit for MAA for a need group of four (the UB is

excluded from the MAA need and benefit group), Sam and his child

are not eligible for EXT.





*However, if Mona’s income had been below $795, this income, by

itself, would not have made Sam and his child ineligible for MAA,

so the increase of Sam’s earned income would make Sam and his

child EXT eligible.



A person who leaves the EXT household for short periods is considered to still be in the



following:




work;






A child gone for illness, social service or educational reasons. They are no longer

in the household if they are admitted to a Medicaid facility such as a nursing home

or residential treatment facility for more than 30 days;




The EXT filing group is the people from the household group whose circumstances are



When an EXT household group member is in more than one filing group for the same

program, the filing groups must be combined, unless specified otherwise in

administrative rule.

For EXT, the filing group must include a dependent child or unborn. The dependent child

must be under 18 years of age or age 18 and regularly attending school full time.




People in the EXT household group are included in the EXT filing group because of their



Parents of an unborn;

Siblings of the dependent child. Siblings must be under 18 years of age or age 18

and attending school full time. (See below for exceptions for siblings receiving

adoption assistance or for siblings who are minor parents.);

For needy caretaker relatives of the dependent child, their spouse, and their

dependent children;

Caretaker relatives.

A dependent child is not included in the EXT filing group if he or she has been or will be

receiving foster care payments for more than 30 days, is receiving adoption assistance, or

is receiving Title IV-E subsidized guardianship assistance payments.




The EXT financial group is the filing group members whose income and resources count

in determining eligibility and benefits.

For EXT, the financial group includes all the people in the filing group except the

following:

Caretaker relatives (other than parents) who choose not to be included in the need

group. These people are known as non-needy caretaker relatives.

People receiving SSI benefits.


Need group (what income standards is used?)



to use.

For EXT, the need group includes all members of the financial group except for

individuals who do not provide a Social Security number or proof they applied.

Need Group: 461-110-0630









For EXT, the benefit group consists of members of the need group who meet all financial

and non-financial eligibility criteria.


CAWEM

Noncitizens who meet all the financial and nonfinancial eligibility requirements of a

program except for their citizenship/alien status are eligible for limited emergency

medical assistance through CAWEM.

Noncitizens who are eligible for and receiving MAA/MAF CAWEM and lose their

eligibility because they went over the MAA/MAF income standard due to an increase in

earned income or child support could be eligible for EXT CAWEM.


4. Verification

Verify the following eligibility requirements for EXT:

For initial EXT eligibility based on an increase in child support verify that at least

one person in the EXT filing group received MAA or MAF for three of the six

months preceding the first of the EXT eligibility period;


legal immigration status.



5. EXT CM coding and support

When EXT eligibility is based on increased child support:

EMS with end date = fourth month;

Enter this N/R when converting a CM case to EXT. The end date should be the

fourth month of the EXT eligibility period;

The CM case will automatically close at the end of the fourth month. A DHS 945

will be mailed to the client in the third month.








When EXT eligibility is based on increased earned income:

AE2 with end date = 12th month;

Enter this N/R when initially converting a CM case to EXT. The end date should

be the 12th

month of the EXT eligibility period. An EXT approval notice will

automatically be mailed to the client.

6. EXT effective date

The budget month used for the EXT determination is the month the client timely reports

increased earnings or child support that will make them over the MAA/MAF income

limit. If reported timely, start EXT medical the first of the month following the last

month of MAA/MAF eligibility. No 10-day notice is required. Because no 10-day notice

is required, some TANF/MAA cases will convert to TANF/EXT before the TANF can be

closed. An individual can receive TANF and EXT on the same CM case.

Example: Paul and Paula have been receiving MAA for the last six months.

On December 30, they report timely that Paul has a new job and

they will be over income for MAA in January. Begin EXT medical

effective January 1.

Example: Dave and his family have been on MAA for the last five months

when the worker gets information in June that Dave is working

and has been over income since February, four months ago. The

worker determines the family was EXT eligible in February, with a

12 month EXT period from February 1, 2012 to January 31, 2013.

To do this now, the worker will begin the EXT on UCMS effective

the beginning of this month and send an MSC 148 to Maintenance

Client.

Example: Betty and her children are on MAA. Betty reports March 1 that she

got a job February 23 and will be over income for March. Because

she reported timely, her EXT will begin the beginning of the

following month, on April 1.

If an MAA/MAF client does not report an increase in income or child support timely,

they may still be eligible for EXT. Determine EXT eligibility based on the month they

went over income for MAA/MAF. If not reported timely, the budget month is the month

before the month the client exceeded the MAA/MAF income limit due to increased

earnings or child support.

Example: Donna and Les began receiving MAA in June 2011. Les received a

raise in August 2011, but did not report it. When they were due for

a SNAP redetermination in December 2011, the eligibility worker

realized they went over income for MAA several months earlier, in

August 2011. They were transitioned to EXT, but the 12-month






EXT period began in August 2011, and will continue through July

2012.

Reminder: When the family goes over the income limit due to an increase in child

support, make sure the family has met the “three-of-six” months MAA/MAF criteria.


Specific Requirements; EXT: 461-135-0095

Eligibility Period; EXT: 461-135-0096

Earned Income, Treatment: 461-145-0130


7. EXT eligibility

When EXT is based on an increase in earned income, there is no requirement that the

family received MAA/MAF for three of the six months prior to the beginning of the EXT

period. However, to qualify for EXT based on increased earnings of the caretaker

relative, the person has to have been eligible for and receiving MAA/MAF and then went

over income.

If eligibility is a result of increased earnings of the caretaker relative, the eligibility

period is for 12 months.

If a filing group meets the eligibility requirements for EXT based on a combination of

increased income from the caretaker relative's earnings and child support, even if either

increase by itself does not make the filing group ineligible for MAA or MAF, the filing

group's eligibility period is based on increased earnings.

If eligibility is a result of increased income due to child support, the eligibility period is

for four months. For EXT based on an increase in child support, the following

requirements apply:

At least one member of the MAA/MAF filing must have been eligible for and

receiving MAA/MAF in three of the six months prior to the beginning of the EXT

eligibility period;

Do not count months the family received Medicaid in another state towards the

three-of-six months requirement;

Do not count months the family received Medicaid in another state towards the

three-of-six months requirement;

The three-of-six month requirement does not have to be consecutive months;

If MAA/MAF was received for at least one day in a month, the whole month is

counted;








Retroactive MAA/MAF eligibility counts in determining if the filing group meets

the three-of-six months requirement for a family that goes over the income limits

due to an increase in child support.

Members of a benefit group who become ineligible for EXT may regain eligibility for

EXT if they again meet EXT eligibility requirements during the original EXT eligibility

period.

Example: EXT ended for John and his two children when they moved out of

state. They moved back to Oregon and again met the eligibility

requirements for EXT.

John and his children may be eligible to receive EXT for the

remainder of the original EXT eligibility period.

Example: Don, Cheri and their daughter Jenny are receiving EXT. Don

moved out of the household. Cheri and her daughter continue to

receive EXT, but Don loses eligibility.

If Don returns to the household, he may regain EXT eligibility for

the remainder of the EXT eligibility period.

Example: Mary and her children are receiving EXT with an AE2 and date of

12/XX. The family becomes eligible for MAA in 6/XX due to a loss

of earned income. During the MAA period, in 09/X, the household

begins receiving UC. The UC puts the family over income for

MAA. The family can regain EXT eligibility for the remainder of

the original EXT period, 12/XX.

If there is no EXT eligibility, review for OHP.

FSML – 70C Medical Assistance Programs G –

August 23, 2013 OHP Medical Programs G - 1

G. OHP Medical Programs

1. OHP eligibility categories; overview

The Oregon Health Plan program provides medical assistance to many low-income

individuals and families. The program includes five categories of people who may

qualify for benefits:

Oregon Health Plan for Nonpregnant Adults; OHP-OPU Standard. This

category consists of uninsured adults who qualify for medical assistance with

income under 100 percent of the federal poverty level (FPL) income standard. A

person eligible under OHP-OPU is sometimes referred to as a health plan

new/noncategorical (HPN) client.

Effective July 1, 2004, OHP-OPU closed to new applicants. To be eligible for this

program, an applicant must be randomly selected from the Standard Reservation

List (SRL) or recertifying or transitioning from OHP-OPU or another Medicaid

program without a break in assistance. OPU adults who enroll in other insurance

can lose medical eligibility prior to the end of their certification period;

Oregon Health Plan for Children; OHP-OPC. This category consists of

children who qualify for medical assistance with income under 100 percent FPL.

Non-CAWEM OPC children may qualify for Continuous Eligibility for Medicaid

(CEM) if they lose eligibility for OPC prior to their next scheduled 12-month

certification;

Oregon Health Plan for Children; OHP-OP6. This category consists of children

under the age of 6 who qualify for medical assistance with income from

100 percent up to 133 percent FPL. Non-CAWEM OP6 children may qualify for

Continuous Eligibility for Medicaid if they lose eligibility for OP6 prior to their

next scheduled 12-month certification;

Oregon Health Plan for Pregnant Females Under 185 Percent and Newborn

Children; OHP-OPP. This category consists of pregnant females who qualify for

medical assistance with income under 185 percent FPL. This category also

includes their newborn children. Newborn children are coded as OPP only if the

OHP countable income at the time they were added to the case is above

133 percent. If 100 percent to 133 percent, code as OP6. If less than 100 percent,

code as OPC. If 133 percent to 185 percent FPL, code as OPP. Children born to an

OPP client is considered an assumed eligible newborn (AEN). The newborn is

guaranteed medical assistance for one full year unless they move out of state or

request for the assistance to end;

Oregon Health Plan for Persons under 19; OHP-CHP. This category consists

of uninsured persons under the age of 19 who qualify for medical assistance with

income at or under 300 percent FPL. This program is authorized by the Children’s

Health Insurance Program (CHIP) provision of the Federal Balanced Budget Act

of 1997 (title XXI) and is not a Medicaid (title XIX) program. CHP children may

Medical Assistance Programs G – FSML – 70C

G - 2 OHP Medical Programs August 23, 2013

qualify for Continuous Eligibility for CHIP (CEC) if they are pregnant and then

lose eligibility for CHP prior to their next scheduled 12-month certification due to

aging off at age 19, and they are not eligible for another plus medical program.

2. Application for OHP

When people apply for OHP medical assistance and another program such as SNAP or

child care, they use the Application for Services (MSC 415F) form. When applying for

medical only, they may use the MSC 415F, Application for Oregon Health Plan and

Healthy Kids (OHA 7210) form, Oregon Health Plan (OHP) Standard Reservation List –

OHP Application (OHP 7210R) or Oregon Health Plan Application (online form)

(OHP 7210W).

When a person is in a hospital and becomes ineligible for OHP because they no longer

meet the age requirement for their category, they can continue to be eligible for OHP

until the end of the month in which they are discharged from the hospital.

3. OHP programs; eligibility requirements and standards

To qualify for medical assistance under the OHP program, a person cannot:

Be receiving or deemed to be receiving SSI benefits;

Be eligible for Medicare, unless the person is a pregnant woman;

Be receiving Medicaid assistance through another program; or

Be enrolled in a health insurance plan subsidized by the Family Health Insurance

Assistance Program (FHIAP).

After considering MAA and MAF, always determine eligibility for children beginning

with OHP-OPC, before moving on to the other three categories. If the family's income

exceeds the OHP-OPC income limit (100 percent), determine if the children might

qualify under other categories, such as OHP-OP6, OHP-OPP or OHP-CHP.




OHP-OPU; standard

This category includes uninsured nonpregnant adults who are in a filing group with

income under the (OHP-OPU) 100 percent income limit, and countable resources below

$2,000.










To be eligible for OHP-OPU, a person must be 19 years of age or older and must not be

pregnant. An OHP-OPU person is referred to as a health plan new/noncategorical (HPN)

client.

There are four groups of medical applicants that may be considered for OHP-OPU:

Clients recertifying for OHP-OPU benefits without a break in assistance;

Family Health Insurance Assistance Program (FHIAP) recipients who indicate to

FHIAP they are willing to move to OHP Standard when notified that their FHIAP

subsidy will end due to budget shortfalls on or after November 30, 2012;

Clients converting from child welfare medical, BCCM, EXT, GAM, MAA, MAF,

OHP-OPC, OHP-CHP, OHP-OPP, OSIPM, OYA, REFM or SAC to OHP-OPU

without a break in assistance; and

Persons randomly selected from the OHP Standard Reservation List. To qualify,

the randomly selected person can establish a DOR on or after the random selection

date through 45 days from the date the Oregon Health Plan (OHP) Standard

Reservation List – OHP Application (OHP 7210R) was mailed.

Note: Individuals whose names are added to the Standard Reservation List are sent an

Application for Oregon Health Plan and Healthy Kids (OHA 7210) with the

words “7210P” and “confirmation application” on the label. DHS/AAA offices

may receive these OHA 7210 applications. Workers at local branches should date

stamp and forward these applications to the OHP Statewide Processing Center

(Branch 5503). Branch 5503 will process these applications.

SEE WORKER GUIDE #7 (MA-WG#7) FOR MORE INFORMATION ABOUT THE

OHP STANDARD RESERVATION LIST PROCESS.

“Without a break in assistance” also means a client on child welfare medical, BCCM,

EXT, GAM, MAA, MAF, OHP-CHP, OHP-OPC, OHP-OPP, OSIPM, OYA medical,

REFM or SAC who establishes a DOR for medical benefits prior to their current medical

program benefits ending. It could also mean their worker re-evaluated the client's medical

eligibility because of a reported change or eligibility review.

Persons randomly selected from the OHP Standard Reservation List must establish a

DOR within 45 days from the date the OHP 7210R is mailed. If the OHP Standard

Reservation List applicant does not establish a DOR within 45 days, the client may

request an ADA accommodation. If the client does not qualify for an ADA

accommodation, treat as a new OHP-OPU applicant.

Example 1: John is under age 60 and not receiving any medical benefits, but

has been signed up for the OHP Standard Reservation List. The

application sent out when John signed up for the reservation list

has already been denied as he had not yet been selected.



http://dhsmanuals.hr.state.or.us/EligManual/PDF/08ma-wg7.pdf



He is randomly selected from the SRL on May 25 and calls his

local SSP branch office to establish a DOR on June 5. The

designated branch person adds his DOR to the Reservation List

website and tells John he will get an application in the mail.

John submits an MSC 415F application and says he has an

emergent need for medical. Following his branch’s emergent need

process, his OHP-OPU eligibility is pended. The worker updates

the pend reasons on the Reservation List website. Later John turns

in the pended items. The worker opens his CM system case and

updates John’s reservation on the Reservation List website to show

John has been approved for OHP-OPU.

John is coded: C/D OPU

N/R HPI C 0.00

N/R STD 0612

N/R LST C 012345

Example 2: Tina is a single adult who is not pregnant, has no children, and

has no disabilities. She is currently not receiving benefits under

any DHS medical program and was not randomly selected from

the OHP Standard Reservation List. She is a new applicant for

OHP-OPU.

Example 3: Marvin is a single adult who was selected from the OHP Standard

Reservation List on October 15. He was mailed a letter letting him

know he had been selected and that he needed to establish a DOR

within 45 days of the date the OHP 7210R was mailed. The

OHP 7210R was mailed on October 26; the 45th

day was

December 12.

On January 15, Marvin called his local SSP office and asked for

medical. He is a new applicant and is ineligible for OHP-OPU

because he did not establish a DOR within the allowable time

frame.

Example 4: Curt is receiving OHP-OPU. His certification ends on August 31.

Curt submitted the OHA 945 pended information in August. Since

Curt has provided the necessary information timely, he can be

considered for OHP-OPU.

Example 5: Larry and his children are receiving OHP medical. He is sent the

OHA 945 pend in June based on a certification period ending

July 31, and his case is automatically BED’d for August. He does

not respond by July 31, and the system automatically closes him

with timely notice for August 31.






He turns in his recertification on September 1. His family is not

eligible for MAA or MAF. Although his children can be considered

for OHP, Larry is a new applicant and is ineligible for OHP.

Example 6: Barry was selected from the OHP Standard Reservation List on

July 15. On July 27, Barry submitted an OHA 7210 application to

recertify his children's medical. On the application, he also

requested medical for himself. The eligibility worker checked on

the Standard Reservation List website and found that Barry had

been selected July 15. Using the July 27 DOR and Barry’s $1,200

income, the worker determined that Barry is eligible for OHP-

OPU benefits and opened Barry's OHP Standard benefits effective

July 27.

Barry is coded: C/D OPU

N/R HPI C 1200.00

N/R STD 0712

N/R LST C 001234

Example 7: Mary turned in an OHA 7210 on August 20 with a DOR of

August 15. The worker checked on the OHP Standard Reservation

List and discovered that Mary was selected on July 15 and an

OHP 7210R will be mailed September 10. Using the August 15

DOR and the August budget month, the worker determined Mary

was over income for OHP-OPU in August. Mary indicated her

income would drop for September, so the worker floated the

budget month to September and determined Mary qualified for

OHP Standard benefits effective September 1 with her anticipated

income of $906. Since even an initial full-month prorated month

does not count toward the 12-month OHP-OPU certification,

Mary's certification end date is September 30, 2012.

Coding for Mary: C/D OPU

N/R HPI C 906.00

N/R STD 0912

N/R LST C 000234

Example 8: Raul calls and establishes a DOR on October 2. Support staff

narrates and sends Raul an application. November 2, Raul’s

application arrives at the branch. The worker sees that Raul has

been selected from the list on October 15. The worker processes

Raul’s application and finds him eligible for OPU based on

income or resources. The worker starts medical on the selection

date of Oct 15.





Coding for Raul: C/D OPU

N/R HPI C 0.00

N/R STD 1012

N/R LST C 000234

In addition to other OHP eligibility requirements, an OHP-OPU client:

Must not be covered by private major medical health insurance. Private major

medical health insurance means private or employer-sponsored health insurance

that provides inpatient and outpatient medical, physician, lab, x-ray and

prescription benefits for each covered individual;

Must not have been covered by private or employer-sponsored major medical

health insurance during the six months preceding the effective date for starting

medical benefits. The six-month waiting period is waived if:

- The person has a condition that without treatment would be life-threatening

or would cause permanent loss of function or disability;

- The person's private or employer-sponsored health insurance premium was

reimbursed under the provisions of OAR 461-135-0990;

- The person's private or employer-sponsored health insurance premium was

subsidized through FHIAP; or

- A member of the person's filing group was a victim of domestic violence.

Note: HNA applicants who are receiving services through Indian Health Services or

HNA applicants who have ESI that the tribe pays for are still eligible for OPU.

You do not have to send an MSC 415H to HIG for Indian Health Services

coverage, but you do need to send an MSC 415H for employer-sponsored or other

private health insurance (excluding Medicare).

Note: Some applicants who receive medical benefits through the Veterans'

Administration (VA) are not eligible for OHP. VA benefits, including CHAMPVA,

are considered major medical. There are VA hospitals in Portland and Roseburg.

There is also a VA hospital in Walla Walla, used by many Oregon veterans. There

are clinics in Eugene, Bandon, Salem, Klamath Falls, Brookings, Bend, White

City and Warrenton. If an applicant has access (or has had access in the prior six

months) to care through a local VA facility (including the Walla Walla hospital),

they are usually not eligible for OHP benefits. If the client says the hospital or

clinic is not accessible or that the Veterans' benefits do not cover their medical

needs, the client may be OPU eligible. If you are not sure, contact a medical

policy analyst.

Must meet the following eligibility requirements:

- OHP resource limit;


https://apps.state.or.us/cf1/DHSforms/Forms/Served/de0415h.pdf




- OHP budgeting requirements;

- Payment of premiums unless exempt.

Certification Period; HKC, OHP: 461-115-0530





Oregon Health Plan Program premiums

When an OHP-OPU benefit group includes one or more nonexempt persons, a monthly

premium is billed to the household. All clients eligible for OHP-OPU, if not exempt, are

responsible for payment of premiums. Clients are exempt from paying a premium if they

meet one of the following:

Have OHP countable income of 10 percent or less of the Federal Poverty Level at

initial application or in the redetermination budget month;

Have American Indian/Alaska Native tribal membership or eligibility for benefits

through an Indian Health Program (HNA Case Descriptor);

Within a certification, an OHP-OPU client leaves the benefit group and the

remaining benefit group's OHP income is reduced to 10 percent or less of the FPL;

When two OHP certified households are combined during a certification and the

combined benefit group’s OHP income is reduced to 10 percent or less of the FPL;

or

Are CAWEM- (CWM Case Descriptor) eligible.

Once the amount of the premium is established, the amount does not change during the

certification period unless one of the following occurs:

An OHP-OPU client becomes pregnant;

An OHP-OPU client becomes eligible for another medical assistance program;

Within a certification, an OHP-OPU client leaves the benefit group and the

remaining benefit group's OHP income is reduced to 10 percent or less of the FPL;

When two OHP certified households are combined during a certification and the

combined benefit group’s OHP income is reduced to 10 percent or less of the FPL.

Note: Unless the filing group meets the criteria in the last two bullets above, do not

adjust or waive premiums during a certification because the filing group’s

income drops.








Note: To adjust premiums when converting from OHP-OPU to an OHP Plus program

(such as OHP-OPP) or when adding an HNA case descriptor, use the MMIS

premium panel. Instructions for how to adjust/waive premiums on MMIS are

available on the SSP medical tool website in the MMIS section.

A premium is considered paid on time when the payment is received by the OHP Billing

Office on or before the 20th

day of the month for which the premium was billed. The day

the payment arrives in the OHP Billing Office’s post office box when it is sent via mail,

or the day it is submitted via phone or online to the billing office is the date it is received.

A premium not paid on time is in arrears.

Note: Once determined eligible, OHP-OPU clients cannot be found ineligible for

benefits during a certification period for failure to pay past due premiums. Past

due premiums only affect eligibility at recertification.

Determining eligibility for OHP-OPU applicants with unpaid premiums

When applying or reapplying under the OHP-OPU program, unless exempt, an applicant

must pay all billed premiums before a client can establish a new OHP-OPU certification

period. An OHP-OPU applicant who does not resolve unpaid premiums during the

application processing time frame at initial application or at redetermination is denied or

closed.

If there are unpaid premiums at initial or re-determination, pend for payment of

premiums as an eligibility requirement. If the unpaid premiums are not resolved within

the application processing time frame, deny or close OHP-OPU medical assistance for

that applicant.

Past arrearage can be canceled if the arrearage was incurred while the person was exempt

from the requirement to pay a premium. Clients with OHP countable income of

10 percent or less of the FPL when the premium is calculated at certification, American

Indians and Alaska Natives, and clients eligible under the CAWEM program are exempt.

If there were any past due premiums owing from before the last recertification, they

should have been resolved prior to approving medical. Allowing past due premiums to

accrue for yet another eligibility period is an agency error. As these premiums can no

longer be pursued for payment, adjust to zero any premiums that were billed but not

resolved at the prior recertification.

The department will not attempt collection on any premium arrearages over three years

old.

Updating the CM case

To waive OHP past-due premiums at recertification for clients with HPI income at

10 percent of less of the FPI, enter a “WE” in the WAIV field on the UCMS screen. The

WE coding only works at recertification and only if the financial group’s income is

http://www.dhs.state.or.us/caf/caf_ss_medical/index.htm



10 percent or less of the FPL. Using the WE code on UCMS in the WAIV field waives

all past-due premiums.

If the premiums have been paid or adjusted to zero, but the CM case still has a “K”

premium status, use the “CD” waiver code to bypass the online edits. If you do not use

the WE or the CD coding, the OHP-OPU's medical will end during overnight processing.

Premium Requirement; OHP-OPU: 461-135-1120

The computer determines the amount of the monthly premium by determining the

number of persons in the need group, their average monthly income and the number of

adults who are required to pay premiums.

The following table may be used to calculate the premium amount:

OHP Premium by FPL

Number in Need Group

Percentage FPL

Premium Amount Billed for Each

Nonexempt OPU Client

1 >10% - 50%

>50% - 65%

>65% - 85%

>85% - 100%

9.00

15.00

18.00

20.00

OHP PREMIUM EXEMPT BY INCOME AMOUNT

Number in

Need Group

10% FPL Income Limit

(income must be equal to or less

than 10% FPL to be premium exempt)

1 95.75

2 129.25

3 162.75

4 196.25

5 229.75

6 263.25

7 296.75

8 330.25

9 363.75

10 397.25

+1 +33.50

OHP Premium Standards: 461-155-0235





Premiums are collected by the Oregon Health Plan Premium Billing Office. OHP

premium bills will state where and how to send in payments.

By mail:

OHP Premium Billing Office

PO Box 1120

Baker City, OR 97814

Payments should be made by check, money order or cashier's check, or over the phone

using Visa, MasterCard or Discover. People who come to a branch office wanting to pay

their premiums should be told to send payments to the above address. The premium bill

includes a return envelope. For questions about the premium bill, payment or a payment

option, the client can call the OHP Billing Office toll-free at 888-647-2729, or TTY:

866-203-8931.

OHP income standards

The income standards for OHP-OPU are as follows.

If a financial group contains a person with significant authority in a business entity - a

“principal” - the gross income of the business entity cannot exceed $20,000.

Oregon Health Plan for Adults (OHP-OPU)

OHP 100% Countable Income Standard

No. in Need Group Amount

1 $958

2 1,293

3 1,628

4 1,963

5 2,298

6 2,663

7 2,968

8 3,303

9 3,638

10 3,973

Each additional person +335



Referrals to Aging & People with Disabilities (APD)

Clients that indicate they have disabilities should be referred to APD, if appropriate,

using your local referral process. Do so only after evaluating for all “Plus” Self-

Sufficiency medical programs.

Check with your lead worker or manager for information about your branch's referral

process for OSIPM. CAF Self-Sufficiency and APD have jointly developed a Worker

Guide explaining the process. The APD WG-4 “Presumptive Medicaid (OSIPM)

Decision Procedures” is available at:

http://www.dhs.state.or.us/spd/tools/program/osip/wg4.htm.

APD referrals for applicants who are potentially eligible for OHP-OPU and a

presumptive referral should have a referral completed immediately, even in cases

where the applicant will be pended for OHP-OPU eligibility.

Clients referred to APD for an OSIPM eligibility decision should be sent the GSOSIPR

“OSIPM Referral” notice available on NoticeWriter. Clients denied for Self Sufficiency

medical prior to the referral will also need to be sent the Notice of Self Sufficiency

Medical Program Eligibility Decision (DHS 462C). The DHS 462C is available on the

DHS forms Web page and as a two-part Notice Writer notice CM462C1 and M462C2.

Clients Required to Obtain Health Care Coverage and Cash Medical Support; CEM, EXT, GAM, MAA,

MAF, OHP (except OHP-CHP), OSIPM, SAC: 461-120-0345


Concurrent and Duplicate Program Benefits: 461-165-0030

OHP; OPC

These are persons under the age of 19 in a filing group with income under 100 percent of

the income standard.


OHP-OPC income standards



1 $958

2 1,293

3 1,628

4 1,963

5 2,298

6 2,633

http://www.dhs.state.or.us/spd/tools/program/osip/wg4.htm

http://dhsresources.hr.state.or.us/WORD_DOCS/DE0462C.doc

http://dhsresources.hr.state.or.us/WORD_DOCS/DE0462C.doc







7 2,968

8 3,303

9 3,638

10 3,973


Oregon Health Plan for children under age 6 (OHP-OP6)

These are persons under the age of six in a filing group with income over the OHP-OPC

(100 percent) income standard, but below the OHP-OP6 (133 percent) income limit.


Oregon Health Plan for children under age 6 (OP6)



1 $1,274

2 1,720

3 2,165

4 2,611

5 3,056

6 3,502

7 3,947

8 4,393

9 4,838

10 5,284


Oregon Health Plan for children (OHP-CHP)

These are persons who may qualify for medical assistance under the Children's Health

Insurance Program (CHIP). The CHIP program is not a Medicaid title XIX program, but

is provided through title XXI, which was a provision of the federal Balanced Budget Act

of 1997. They are under the age of 19, and cannot be eligible under the OHP-OPC, OHP-

OP6, or OHP-OPP categories. The financial group's income must be over the OHP-OPC

(100 percent) income limit for children ages 6 through 18 or over the OHP-OP6

(133 percent) income limit for children under age 6 or over the OHP-OPP (185 percent)

income limit but below the OHP-CHP (at or below 300 percent) income limit.

In addition to other OHP eligibility requirements, an OHP-CHP client must meet all the

following requirements:




Verification of U.S. citizenship or alien status requirements;

Must not be pregnant and eligible with income less than 185 percent (code OHP-

OPP if pregnant and less than 185 percent of the FPL);

Pregnant children (under age 19) with income from 185 percent to 300 percent of

the FPL may receive CHIP. Add the new CDU (CHIP DUE) need/resource item,

unborn child (UB case descriptor) and father of the unborn to the CHIP child’s

CM case;

Note: Eligibility for pregnant CHIP women is limited. If the pregnant CHIP woman

loses CHIP eligibility at redetermination (turning age 19 or at the end of the

CHIP 12-month certification), convert to Continuous Eligibility for CHIP

pregnant children (CEC).

Note: Children born to pregnant CHIP women are assumed eligible for Medicaid for

one year. Code the child as an OHP-OPP AEN on the CM case.

With a few exceptions listed below, the child must not be covered by major

medical health insurance. Major medical health insurance means private or

employer sponsored health insurance that provides inpatient and outpatient

hospital, lab, x-ray, physician and prescription benefits.

Do not delay CHIP eligibility solely because the child is covered by Kaiser Child Health

Program or Kaiser Transitions Program medical. Kaiser will end their medical after the

CHIP medical eligibility is opened. Be sure to send HIG an MSC 415H with the Kaiser

coverage information. Include the information that the coverage does not affect CHIP

eligibility.

Note: Effective March 26, 2010, the OHA Statewide Processing Center (Branch 5503)

will process SSP applications for children in Kaiser Permanente’s Child Health

Program or Transitions Program. Fax the application to 5503 at 503-373-7493.

A cover letter was developed to support the process. Be sure to include the

“Attention” cover letter when faxing the application. The cover letter will be

posted to the SSP medical website the week of March 29.

HNA applicants who are receiving services through Indian Health Services or HNA

applicants who have ESI that the tribe pays for are still eligible for CHIP. Send HIG an

MSC 415H with the Indian Health Service coverage information. Include the information

that the coverage does not affect CHIP eligibility.

Note: Remember the parents of CHIP children should never be forced to apply for,

accept and maintain other health insurance coverage as this is not an eligibility

requirement in the CHIP program like it is in Medicaid.

OHP-CHP income standards

Oregon Health Plan for Children Under Age 19, including Pregnant Females with Income

no less than 185 Percent FPL (OHP-CHP):


http://www.dhs.state.or.us/caf/caf_ss_medical/index.htm




OHP at or below 300% Countable Income Standard


1 $2,874

2 3,879

3 4,884

4 5,889

5 6,894

6 7,899

7 8,904

8 9,909

9 10,914

10 11,919

Each additional person +1,005


Income Standard; HKC, OHP, REFM: 461-155-0225

OHP for pregnant females under 185 percent and their newborn children under one

year of age (OHP-OPP)

A pregnant woman eligible for OHP is not assigned an eligibility period. She is assumed

eligible through the last day of the month in which the 60th

day following her pregnancy

falls. When her assumed eligibility period ends, she needs to reapply to continue to

receive benefits even if the certification period for others in the group extends beyond her

assumed eligibility period. The computer system uses the DUE need/resource date to

determine the period of eligibility. If the pregnancy ends in a month other than the date

coded, it is important to change the DUE N/R date so the person receives the correct

period of coverage.

This category includes pregnant females with income below the 185 percent income limit

and their assumed eligible newborn children at or above the OHP-OP6 (133 percent)

income limit.


We do require a redetermination for everyone in OHP filing group when a pregnancy is

reported for someone in the filing group who is not receiving OHP medical.

For ongoing Medicaid clients (EXT, MAA, MAF, OHP (except OHP-CHP), OSIPM, or

SAC) who report they are pregnant:

If the client is already receiving EXT, MAA, MAF or OSIPM and then reports a

pregnancy, verify the pregnancy and then add the DUE need/resource coding

without a redetermination for the pregnant woman. If the unborn ties the father of






the unborn into the filing group, eligibility may need to be redetermined for others

in the MAA filing group;

If the client is already receiving OPC or OPU and then reports a pregnancy, verify

the pregnancy and then convert to OPP without a redetermination;

For ongoing CHIP clients whose eligibility was determined at185 percent and

above, verify the pregnancy and then add the pregnancy related coding (CDU and

UB coding) without a redetermination.

OHP-OPP income standards

Oregon Health Plan for pregnant females of any age and their Assumed Eligible

Newborn children under age one (OHP-OPP).



1 $1,772

2 2,392

3 3,011

4 3,631

5 4,451

6 4,871

7 5,490

8 6,110

9 6,730

10 7,350









commercial room and/or board establishment. When people live in more than one

household during a month, they are considered to be living in the household where they

spend 51 percent or more of their time.







during the week?






following:




work;






A child gone for illness, social service or educational reasons. They are no longer

in the household if they are admitted to long-term care facility;


For OHP, a child may be in a residential alcohol or drug treatment facility for more

than 30 days and still be considered in the household. However, if the child is in a

residential alcohol or drug treatment facility and the child’s household is ineligible

for OHP because of income, the child then constitutes a separate household.






For OHP, filing groups are formed from the household group. A person forms his or her

own filing group if not required to be in a filing group with another person.

The following people are required to be in the same filing group, even if they are not

applicants or do not meet all nonfinancial eligibility requirements:

People married to each other and each child of either spouse;




The parents of a child or unborn and the children of each parent;

Siblings under the age of 19;

A child whose caretaker relative is not the child's parent may form a separate filing

group or may be in a group with the caretaker relative, at the option of the

caretaker relative.


Filing Group; HKC, OHP: 461-110-0400




For OHP, the financial group includes all the people in the filing group except caretaker

relatives (other than parents) who choose not to be included in the need group.





to use.

For OHP, the need group includes all the people in the financial group. For pregnant

females, also include the unborn child(ren) in the OHP need group.

Need Group: 461-110-0630



For OHP, the benefit group consists of all the individuals who meet all the financial and

nonfinancial eligibility requirements. Individuals who do not provide a Social Security

number or proof they applied are not eligible for medical assistance unless they are only

qualified for CAWEM benefits.


CAWEM

Noncitizens who meet all the financial and nonfinancial requirements of another medical

program (other than OHP-CHP) except for their citizenship/alien status or SSN

requirements are eligible for limited emergency medical assistance. The policy for








forming eligibility determination groups for CAWEM is the same policy for the program

the person would qualify for if they met the citizenship/alien status requirement.



5. Budgeting and income standards

Budgeting is the process of determining whether a person meets all nonfinancial and

financial eligibility requirements in a calendar (budget) month.

OHP budget month

When determining financial eligibility for OHP programs, first determine the initial

budget month. The budget month is the calendar month from which nonfinancial and

financial information is used to determine eligibility and benefit level. The budget month

is one of the following:

For all new applicants, it is the month of application, usually the month with the

DOR;

For people reapplying in the last month of their OHP certification, and for people

moving from another medical assistance program to OHP, it is the last month of

their current eligibility period;

When adding a new person to the filing group, it is the month the person is to be

added;

The month following the initial budget month for applicants who are not eligible

using the budget month described above.

Example 1: On July 19, Ed and Martha request medical for Ed’s 16-year-old

son, Brad, from a previous marriage who has now moved in the

household. Brad had private health insurance that ended on

May 31 when he moved out of his mom’s household.

The worker determines that Brad is only eligible at the CHIP level,

but has not met the two-month uninsurance requirement. Brad

does not meet a reason to waive the two-month uninsurance

period.

Floating the budget month to August, Brad is eligible for CHIP

based on August income and also now meets the two-month

uninsurance requirement. Open CHIP for Brad effective August 1.

Example 2: Pam applies for medical assistance for her child on July 19. She

meets all financial eligibility for July, except that her child had

private health insurance that was scheduled to end at the end of





July because the employer was no longer covering dependents. The

worker floated the budget month to August, and requested the

income Pam received in August. Using financial and nonfinancial

information for August, the child was found eligible for OHP-

OPC. Because the child was eligible for OHP-OPC using the

budget month of August, medical benefits were opened effective

August 1.

Budgeting using the DHS 945

The Medical Notice: It’s time to renew your medical benefits (DHS 945) medical pend

notice is mailed to most SSP medical program clients when a redetermination is required.

The DHS 945 establishes a DOR for medical and is used for SSP medical program

redeterminations only.

Budget month when acting on reported changes

In all SSP medical programs, when acting on reported changes, treat the DOR month as

the initial budget month.

Example 1: An MAA/MAF client reports the loss of their job in June. They

have begun getting UC, and that makes the family over income for

MAA/MAF. The worker determines the family is now eligible for

OHP, based on budget month income from June.

Example 2: On June 15, a client reports a child has returned to the OHP filing

group a few days earlier. Redetermine eligibility for the whole

filing group using June as the initial budget month, and if the child

and everyone else are now eligible for OHP, compute the entire

benefit group out for a new 12-month eligibility period.

Example 3: Edgar is a self-employed artist. He works all year making wood

carvings, and sells them from May to October at an outdoor flea

market. In his off months, he lives off of his savings. He is selected

from the OHP Standard Reservation List in November and applies

for medical assistance on November 23. Based on budget month

income from November, he is eligible for OHP.

For OHP, when a reported change was made that may affect the eligibility, the budget

month is the month of the reported change. This could be when income has dropped and

the family may now be eligible for another medical program, or when a new person has

moved into the filing group.

Example: In June, the OHP client reports a child has moved back to the

household in June. Redetermine eligibility for the whole filing

group using June as the budget month.






For OHP redeterminations, unless required because of a reported change, use the last

month of the certification as the budget month.

When an Application Must be Filed: 461-115-0050

Eligibility and Budgeting; HKC, OHP: 461-150-0055

OHP budgeting and eligibility

Do not annualize, convert or prorate the financial group’s income. Use the gross

countable income available for the budget month.

Calculate the amount of the financial group's income using the following steps:

Include all income already received and income anticipated for the budget month

when determining countable income;

For self-employed clients whose business passes the $20,000 self-employed

business entity income test, the income for the budget month is determined as

follows:

- Exclude 50 percent of the total gross self-employment income;

- If any applicants are not eligible using the 50 percent exclusion, exclude

allowable self-employment expenses from the total gross self-employment

income.

The income for the budget month is used to determine OHP and HKC eligibility for the

need group as follows.

Compare the budget month income to the OHP Countable Income Standards of

100 percent. If the budget month income is below the 100 percent standard and the group

meets all other eligibility requirements, the group is eligible for OHP.

Use the OHP case descriptors for each eligible person as follows:

OPU Nonpregnant adults

OPC Children

OPP Pregnant persons, regardless of age

If the budget month income equals or exceeds the 100 percent income standard,

nonpregnant adults are not eligible. Determine eligibility for the remaining members of

the need group as follows.

Compare the budget month income to the OHP Countable Income Standards of

133 percent, 185 percent and 300 percent, as appropriate. If the budget income is below

an income standard for all remaining members of the need group, and all of these

members of the need group meet all other eligibility requirements, these members of the

need group are eligible for OHP.

Use the OHP case descriptors for each eligible person as follows:





OP6 Children under 6 (with income between 100 percent and 133 percent FPL)

CHP Nonpregnant children (with income above 133 percent but at or below

300 percent FPL)

CHP Pregnant children under age 19 (with income above 185 percent but at or

below 300 percent FPL)

OPP Pregnant persons, regardless of age (with income up to 185 percent FPL)

An assumed eligible newborn (AEN) is coded as OHP-OPC, OHP-OP6 or OHP-OPP,

depending on income level. An AEN at or above 133 percent FPL must be coded OPP.



Use of Income; HKC, OHP: 461-160-0700

Resource limits for OHP

For OHP, there is no resource limit for persons whose eligibility is determined under the

OHP-OPC, OHP-OP6, OHP-CHP, or OHP-OPP categories.

The resource limit for OHP-OPU is $2,000.

OHP $20,000 business entity income test for principals

A “principal” is a person with significant authority in a business entity, such as the

proprietor of a sole proprietorship – including a person who meets the definition of “self-

employed” in OAR 461-145-0910, a partner of a partnership, a member or manager of a

limited liability company or an officer or principal stockholder of a closely held

corporation.

If an OHP financial group includes a principal, the business entity must pass a $20,000

gross income test. The business entity's gross income cannot be prorated among

principals for the purpose of the gross income test.

Calculate the budget month gross income of the business entity. If the budget month

gross business income is less than $20,000, eligibility for OHP can be determined for the

group.



Income Standard, HKC, OHP, REFM: 461-155-0225


If their countable self-employment income is over income standards using the 50 percent

exclusion, then determine countable income by subtracting the allowable business costs











from the total self-employment income. See Counting Client Assets, Section C - Self-

Employment income (CA-C).

Earned Income Tax Credit (EITC) and Making Work Pay (MWP) Tax Credit: 461-145-0140

Self-Employment; Costs That Are Excluded To Determine Countable Income: 461-145-0920

Self-Employment; Determination of Countable Income: 461-145-0930



Earned Income Deduction; MAA, REF, TANF: 461-160-0160



Children who do not qualify for CHP because the family’s self-employment business

does not pass the $20,000 business entity income test are referred to OPHP as KC3 (non-

subsidy HKC).

Example: Bill and Tom are equal partners (both have 50 percent ownership)

and principals in a carpet cleaning business that grosses

approximately $20,500 monthly. Bill applies for OHP (or HKC)

and reports on the application that his share of the gross income is

$10,250. Bill is not eligible for OHP or an HKC subsidy because

the business entity does not pass the $20,000 gross income test. If

otherwise eligible for HKC, the family should be referred to OPHP

as a KC3 (nonsubsidized) HKC referral.

Express Lane Eligibility (ELE) based on findings from an Express Lane Agency

(ELA)

The CHIP Reauthorization Act of 2009 provided the option for states to implement

Express Lane Eligibility (ELE) for Medicaid and CHIP. ELE allows states to borrow

some eligibility findings from other agencies approved by the Oregon Healthy Authority

(OHA) as Express Lane Agencies (ELA), such as WIC and SNAP, and to use those

agencies’ findings to determine medical eligibility for children.

Effective August 2010, OHA/DHS implemented SNAP ELE.

In November 2011, OHA/DHS began to pilot ELE in five school districts using the

National School Lunch Program (NSLP) as an ELA.

ELA findings will be used only at the OHA Statewide Processing Center

(Branch 5503)

NSLP and SNAP income calculations will be used to determine eligibility for the OPC

and CHP programs for children in filing groups where no one is receiving medical

assistance. Cases are placed in OPC or CHP as follows:

Children with SNAP or NSLP income below 163 percent of the federal poverty

level (FPL) are placed in the OPC program;

http://dhsmanuals.hr.state.or.us/EligManual/10ca-c.htm











Children with SNAP or NSLP income at or above 163 percent FPL are placed in

the CHIP program.

Note: If the parents also request medical, the 5503 worker will use the ELA

findings to determine whether the child is OPC or CHP and open medical in

the appropriate program. The 5503 worker will then pend for information

needed for MAA/MAF. If the parents return the pended information and are

eligible for MAA/MAF, MAA/MAF will be opened for the family. If the

parents do not respond to the pend or are not eligible for MAA/MAF, staff

will leave the children on OPC or CHP based on ELE.

New case descriptors, Express Lane SNAP (ELS) and Express Lane NSLP (ELL) have

been created to identify the children found eligible based on an ELA determination.

Using ELE, verification requirements are reduced or eliminated. The following eligibility

factors must still be verified:

Citizenship (open with CIP coding if needed);

Health Insurance information for children eligible for OPC.

Reminder: Children covered by private major medical health insurance are ineligible

for CHIP. When the child is found to have SNAP or NSLP income at or

above 163 percent of the FPL but the child has other health insurance,

they cannot be enrolled in CHIP. Prior to denying or closing medical for

the child, the eligibility worker will need to determine medical eligibility

based on current Medicaid or CHIP policy.

There are reduced verification requirements for:

Absent parent information;

Identity (a parent’s signature on a SNAP application is sufficient for children

under age 16).

There are no verification requirements for the SNAP or NSLP program findings of:

Income;

Filing group size;

SSN;

Residency.




Poverty Related Income Standards; Not OSIP, OSIPM, QMB: 461-155-0180











6. Verification

When people apply for OHP, verify the following eligibility requirements for the initial

application:

Social Security number or an application for a number;

Citizenship. Acceptable evidence of citizenship must be provided for most OHP

recipients as soon as possible after opening benefits. If the client has been pended

but contacts their worker prior to the pend due date and requests more time to

provide documentation, extend the pend period;



Note: If an applicant declares U.S. Citizenship but does not have verification of

citizenship at the time they apply, do not hold up medical assistance for

verification if otherwise eligible. First, look on The Oregon Vital Events

Registration System (OVERS) for verification of citizenship for those

individuals born in Oregon. If not born in Oregon, code with the CIP, and

request an update from TPQY. Once verified, update the person

alias/update screen, narrate and remove the CIP.

Note: If the applicant is otherwise eligible for a medical program and declares

an immigration status that would meet the alien status requirements for

full medical benefits (this does not include CAWEM clients) but does not

have verification of their status, open medical and pend for verification of

immigration status using the CMNCSPD (Pend Medical; Proof of INS

Status) Notice Writer notice and code the CM case with NOP.



The pregnancy of a client must be verified by a medical practitioner, health

department, clinic or crisis pregnancy center or similar facility;

Note: The due date does not need to be verified; accept the client’s statement unless

questionable.

Income source: If no verification is available, accept the client’s statement.

Verify the following when an OHP case is being recertified:



The pregnancy of a client must be verified by a medical practitioner, health

department, clinic or crisis pregnancy center or similar facility;





Income source: If no verification is available, accept the client’s statement.






In the OHP-OPU Program:

If an OHP Standard Reservation List Applicant establishes a DOR on or after the

random selection date through 45 days after the OHP 7210R mail date, begin

benefits on the date of request if otherwise eligible on that date;

If an OHP Standard Reservation List Applicant establishes a DOR 45 days before

the selection date, begin benefits on the date the applicant was randomly selected,

if otherwise eligible on that date.

In the OHP program:

If the client meets all eligibility requirements on the date of request, begin medical

effective the date of request;

If the client does not meet all eligibility requirements on the date of request, it is

the first day in the application processing timeline following the date of request

that all eligibility requirements are met within the month of the date of request or

the following month if ineligible the month of the date of request.






8. OHP certification period

The intent of the OHP certification period is to give most people a continuous period of

medical assistance and to review their eligibility on a periodic basis.

The certification period is the number of months between the person's initial eligibility

and when a recertification of eligibility is due, or between one recertification and the

next. The certification period is determined as follows:









For OPC, OP6, OPU and CHP clients, the initial certification consists of the month

containing the effective date for starting medical benefits and the following

12 months. For example, if the DOR is 05/15/10 and the client is eligible for OPC,

OP6, OPU or CHIP from this date, the certification period would be 05/15/10-

05/31/11;

For OPC, OP6, OPU, and CHP recipients, the new certification period is the

following 12-month period;

A pregnant woman eligible for OHP is not assigned an eligibility period. She is

assumed eligible through the last day of her pregnancy and for the following two,

full months. When her assumed eligibility period ends, she needs to reapply to

continue to receive benefits even if the certification period for others in the group

extends beyond her assumed eligibility period. The computer system uses the DUE

need/resource date to determine the period of eligibility. If the pregnancy ends in a

month other than the date coded, it is important to change the DUE need/resource

date so the person receives the correct period of coverage;

When a person receiving OHP starts working under a JOBS Plus agreement,

extend the certification period to one month beyond the end of the agreement. If

the agreement ends early, shorten the period to the original date or the month

following the month in which the agreement ends, whichever is later;

When an individual has been found eligible for OHP-OPC, OHP-OP6, OHP-CHP, and

OHP-OPU, they are given a 12-month eligibility period. Reporting requirements are

limited during this eligibility period. They must report the following:

A change in availability of employer-sponsored health insurance;

A change in health care coverage;

A change in mailing address or residence;

A change in name;

A change in pregnancy status of any member of the filing group (see

OAR 461-110-0400).

Unlike MAA or MAF which is based on monthly eligibility, an OHP client who reports

an income increase will not need to have their eligibility reviewed during the 12-month

eligibility period. They have been found eligible for a 12-month eligibility period unless

they age off or move out of state.

Note: A CHIP or OPU client who obtains ESI or private health insurance should have

their CHIP or OPU benefits closed prior to the end of their CHIP or OPU

eligibility period.

If an OHP-OPU client reports they may now be eligible for Plus medical based on a

decrease in income, that information establishes a date of request and eligibility must be




reviewed for the better medical program. If they are not found eligible for the Plus

medical program, their OHP benefits must continue through the end of their current

eligibility period.

When a person is in a hospital and becomes ineligible for OHP because they no longer

meet the age requirement for their category, they can continue to be eligible for OHP

until the end of the month in which they are discharged from the hospital.

How to recertify BED’d cases: If eligible for OHP, any month the client receives

benefits because the case had been BED’d counts toward the next OPC, OP6, CHP or

OPU certification period.

When recertifying a BED’d case, remove the BED code. Enter a Compute action for the

first of the next month. Change the medical case descriptor if necessary and update the

OPC, OP6, CHP or OPU need/resource end date. Change the medical start date on

CMUP for the recertified client to the first of the next month.

Example: An OPC child's certification is due to end April 30. On April 14,

the family reapplies for OHP benefits and the case is BEDded for

06/11. On May 5, the child is determined to be eligible for CHP.

Remove the BED code. Compute for June 1, 2011 and enter a CHP

need/resource end date of 04/12. Change the child's medical start

date to June 1.

Adding/removing persons from an OHP case: When a new person (other than an

assumed eligible newborn) wants to be added to an ongoing case, the entire group must

establish a new certification period. If the new certification would make the current

benefit group ineligible, the original benefit group remains eligible for the remainder of

their certification period.

Example: Mary and her two daughters are receiving OHP. Her son John had

been living with his father, but has returned to live with Mary and

his sisters. John is not receiving any health care coverage, so

Mary applies for medical for John on October 15, 20XX.

Determine eligibility for Mary, her two daughters and John. If

eligible, recertify Mary and her two daughters (giving them a new

12-month certification) and certify John from October 15 through

October in the following year.

Note: If John is not eligible for medical, send a denial notice and DHS 462A notice.

Keep Mary and her two daughters on their original certification.

When a person leaves an OHP benefit group, that person remains eligible through the end

of the eligibility period as long as he or she meets the nonfinancial and specific program

requirements. Those remaining in the original benefit group also remain eligible through

the end of the certification period if they continue to meet the nonfinancial and specific

program requirements. A different case will need to be opened for the person who left the




group. If the person is paying premiums as required under the OHP-OPU program, the

premium status (K or C status) from the original case will not be updated on the new

case. When a couple on OHP-OPU separate, the premium can go down for one or both of

the adults, but a premium should never go up. The number in the filing group can be

manipulated to ensure the premium does not increase in this circumstance. Narrate

carefully.

Example: Jim, Debbie and their child are on OHP. Jim and Debbie have

OHP-OPU; the financial group’s income is $1,500 so each adult

pays a $20 premium.

Jim leaves the household and the worker moves him to his own

OHP-OPU case. His income was $900 of the total family income;

his premium will remain at $20.

Debbie’s income was $600 of the total family income; her premium

for a filing group of two will now be $6.

Combining OHP households: When a recipient moves into the household of another

recipient, the filing group must be combined into one case if all of the recipients are

required to be in the same filing group.

When cases are combined, extend the certification period to the latest date for any of the

persons in the group.

Effect of reported changes on the certification period: Once a person is determined

eligible for OHP, any changes in the filing group's household composition, income or

resources, does not affect their eligibility during their current certification period.

However, other changes (such as residency and citizenship) can affect eligibility.





FSML – 65A Medical Assistance Programs I –

May 1, 2012 Twelve-Month Continuous Eligibility for Non-CAWEM Children I - 1

I. Twelve-Month Continuous Eligibility for Non-CAWEM Children

1. Continuous eligibility for Medicaid (CEM) overview

Effective October 2009, non-CAWEM children under age 19 who lose eligibility for

EXT, CW medical, MAA, MAF, OHP, OSIPM or SAC medical may qualify for medical

under CEM.

CEM is title XIX medical assistance for a non-CAWEM child found eligible for

Medicaid who then loses his or her eligibility for a reason other than turning 19 years of

age or moving out of state. The child is deemed eligible for Medicaid for the remainder

of the 12-month eligibility period.

Note: CW children are also eligible for 12-month continuous eligibility. If a child’s CW

medical ends before the child’s next scheduled 12-month redetermination, the

medical is transitioned to SSP or SPD medical. This may include CEM.

Begin CEM when the child:

Was eligible for and receiving EXT, CW medical, MAA, MAF, OHP or OSIPM, but lost

eligibility for the program before the child was able to receive Medicaid for 12 full

months from their most recent eligibility decision (either the initial eligibility decision or

from the most recent redetermination).

To qualify for CEM, the child must also:

Be under age 19;

Be a citizen or meet the alien status requirement for medical.

Note: Effective October 2009, LPR children (under age 19) meet the alien status

requirement and qualify for full Medicaid and CHIP benefits without having to

wait for five years.

LPR children turning age 19 may no longer qualify for full medical program

benefits. When a child is turning age 19, determine if the 19-year-old’s LPR

status began less than five years ago. If it began less than five years earlier,

consider eligibility for CAWEM benefits.

SEE NONCITIZEN’S WORKER GUIDE #1 (NC-WG#1) FOR MORE INFORMATION

ABOUT IMMIGRATION STATUS REQUIREMENTS FOR MEDICAL.

CEM benefits end when:

The child has received Medicaid for 12 straight months since their most recent

eligibility decision (either the initial eligibility decision or from the most recent

redetermination);

http://apps.state.or.us/caf/fsm/15ncwg1.htm

Medical Assistance Programs I – FSML – 65A

I- 2 Twelve-Month Continuous Eligibility for Non-CAWEM Children May 1, 2012

The child moves out of state;

The child turns age 19;

The family voluntarily requests the medical be closed.

Procedures and examples

When there is a change that ends the child’s eligibility for EXT, CW medical, MAA,

MAF, OHP, OSIPM and SAC (other than a regularly scheduled redetermination of

medical assistance) and the child is determined no longer eligible, review for all medical

programs as per the usual “due process” procedure.

If the child is found ineligible for EXT, MAA, MAF, OISPM, OHP, QMB and SAC

medical programs, consider if the child is a U.S. citizen or meets the Medicaid/CHIP

alien status.

If the child is a U.S. citizen or meets the Medicaid/CHIP immigration status, convert to

CEM for the remainder of the 12 months since their prior eligibility determination. Enter

the CEM need/resource item and case descriptor. For the CEM end date, use the end of

the 12-month period (counting from either the initial eligibility decision or from the most

recent redetermination).

Example 1: Regina is receiving OP6; her certification is due to end

November 30, 20XX. On June 10, Regina turns six years of age. A

redetermination is initiated, and Regina’s household now has

income over 201 percent of the FPL. The worker determines

Regina is only eligible for CEM. The worker codes Regina with the

CEM case descriptor and N/R for 11/20XX.

Example 2: Seth is receiving MAA. His LPR status date is January 2008. His

MAA redetermination N/R end date is January 31, 20XX.

On October 2, Seth’s mother reports that her husband has

returned home and that he earns about $3,000 a month. Acting on

the reported change, the worker determines that the family is not

eligible for EXT, MAA, MAF, OHP, OSIPM or SAC and ends

medical for the mother (sending a 10-day close notice and

DHS 462A). The worker reviews Seth’s eligibility and finds Seth is

eligible only for CEM. The worker enters the CEM case descriptor

and CEM N/R item for 01/20XX.

Example 3: Mark and his two children are receiving MAA. No one meets the

disability criteria for OSIPM presumptive. In July, Mark reports

an increase in child support that makes the family ineligible for

MAA. The worker converts the family to EXT for four months, from

August 1, 20XX, through November 30, 20XX.




In November, Mark reports he has a new job with health

insurance. No one in the family is eligible for MAA, MAF, OHP

(or OSIPM or SAC). The children are converted to CEM for the

remainder of the 12 months following the last review in July. The

worker enters the CEM case descriptor and CEM N/R item on

each CEM eligible child. The CEM N/R end date is July/20XX.

Example 4: Maria and her two children, Consuela and Antonio, apply for

medical assistance with a DOR of June 2. Maria and Consuela are

MAA eligible; Antonio does not meet the qualified alien status

requirements and so is only eligible for MAA CAWEM. The review

date is June 2013.

On August 5 Maria reports she has married and the family is now

over income for MAA, OHP and CHIP. There is no EXT eligibility.

Maria is reviewed for OHP-OPU but is over income. The worker

sends timely notice (DHS 456 and DHS 462A) to end medical for

Maria. Consuela is eligible for CEM through June 2013. Antonio

is not eligible for CEM as he does not meet the qualified alien

status requirements; his medical is closed with timely notice

(DHS 456and DHS 462A).

Procedures for CEM children turning age 19:

CEM: Children turning age 19 are no longer eligible for CEM unless pregnant. If

pregnant, the CEM child will receive protected benefits through the end of the second

month following the DUE date.

CEM: Children turning age 19 are no longer eligible for CEM unless pregnant. If

pregnant, the CEM child will receive protected benefits through the end of the second

month following the DUE date.

CEM children will be mailed advance and final close notices and a redetermination

packet (DHS 945). If there is a date of request (DOR) established before the CEM ends,

add a BED code. Review for medical program eligibility and convert to a new program or

end medical benefits with a 10-day close notice and DHS 462A.

OSIPM children under age 19 may qualify for CEM if they lose OSIPM eligibility prior

to their next scheduled 12-month redetermination.

Qualified Medical Beneficiaries (QMB) children do not qualify for CEM.

2. Continuous eligibility for OHP-CHP (CEC) overview

CEC is title XXI medical assistance for a pregnant non-CAWEM child found eligible for

the OHP-CHP program who loses her eligibility for a reason other than moving out of









state or becoming a recipient of private major medical health insurance. The pregnant

individual is deemed eligible for OHP-CHP through the last day of the month in which

the pregnancy ends.

Begin Continuous Eligibility for CHIP (CEC) when the child:

Is pregnant;

Is under the age of 20;

Is a citizen or meets the alien status requirement;

Is eligible for and receiving CHIP; but

Loses eligibility for CHIP for a reason other than private major medical insurance.

The CHIP pregnant woman who loses her eligibility for a reason other than private major

medical insurance should be reviewed for possible OPP or another Medicaid program

first. If the only program the CHIP pregnant woman is eligible for is CEC, convert from

CHIP to CEC.

CEC benefits end when:

Pregnancy ends;

They move out of state;

They request to close medical; or

Private major medical insurance begins.

A pregnant child receiving CHIP with household income from 185 percent up to

201 percent will have a new N/R code; CDU. The N/R date will be the month the

pregnancy is due to end. This is different from a child who is pregnant with household

income below up to 185 percent FPL: that child will be coded OPP.

If the CDU date (CHIP Due date) is on or before the 15th

of the month, the CEC end date

is the same month as the CDU end date.

If the CDU date is after the 15th

of the month, the CEC end date will be the next month to

allow for 10-day notice.

When notified the baby has been born to a woman coded CEC, add the BED coding to

the mother and initiate a redetermination of eligibility.

Example 1: Bailey is age 17, receiving CHIP with a CHIP certification end

date of November 2012, and pregnant with a CDU (due) date of

3/23/13. At recertification, the family is over the CHIP income

limit. The worker converts Bailey to CEC with a N/R of March



2013. Bailey’s CEC will end at the end of March 2013 unless she

initiates a redetermination and is eligible for medical at that time

or lets the worker know she is still pregnant at the end of March

2013.

Example 2: Amanda is age 18, pregnant and due December 2012. She is coded

CDU for December 2012. Her CHIP benefits began in August

2012; she is coded CHP with a redetermination date of July 2013.

Her baby is born in December 2012. Because Amanda is still age

18 when the baby is born, she continues as CHP with a

redetermination date of July 2013. However, Amanda turns age 19

in February 2013. Because she is no longer pregnant, and is now

19 years of age, her CHIP benefits will end. She must be

considered for other medical programs prior to closing or

reducing benefits.

Example 3: Shelby is an 18-year-old child currently receiving CHIP with a

redetermination in June 2013. She is pregnant with a due date of

February 23, 2013. In December 2012, she turns age 19, and is no

longer eligible for CHIP. The worker determines the only program

she is eligible for is CEC. The worker changes her program to

CEC (with a CDU date of 2/2013). However, because the due date

is past the 15th

of the month, the CEC date is the following month,

or 3/2013, to allow time for notice. When the baby is born, her

CEC benefits will end. She may be eligible for another medical

program at that time.

Example 4: Tara is 18 years old and receiving CHIP with household income

from 185 percent up to 201 percent of the FPL, coded with a

redetermination date of 12/2012. In August 2012, she brings in

proof of pregnancy; she is not due until March 2013. The worker

adds the CDU with a due date of 3/2013. At her December

redetermination, her household income is now above 201 percent

FPL. The worker codes her CEC for 3/2013 and CDU for 3/2013.

Example 5: Bethany, an 18-year-old who is pregnant with a due date of March

2013, is receiving CHIP and scheduled for redetermination in June

2013. Bethany receives major medical health insurance through an

absent parent in December 2012. She is no longer eligible for

CHIP, and is not eligible for CEC due to the major medical health

insurance. The worker closes her benefits December 2012 after

sending a timely closure benefit notice DHS 462A.

Special 5503 MAA/MAF/OPP procedure:

The OHP Statewide Processing Center (Branch 5503) will work a monthly report of

pregnant children who:




Are in the final month of their protected eligibility;

Are under age 19; and

Have no dependent children on the case.

The report will also list OPP children whose medical is ending.

Example: Felicia is age 16 and receiving OPP. The DUE date on her CM

case is 08/12. In 10/12, a newborn has not been added and there

are no other children listed on the case. 5503 will initiate a

redetermination of eligibility for Felicia’s medical filing group.

FSML – 67 Medical Assistance Programs J –

October 1, 2012 Breast and Cervical Cancer Treatment Program (BCCTP) J - 1

J. Breast and Cervical Cancer Treatment Program (BCCTP)

The Breast and Cervical Cancer Prevention and Treatment Act of 2000 (Public Law

106-354) amended title XIX (Medicaid) of the Social Security Act to give the option of

providing Medicaid eligibility to uninsured women who are screened by the Centers for

Disease Control and Prevention's National Breast and Cervical Cancer Early Detection

Program (NBCCEDP) and are in need of treatment for breast or cervical cancer,

including precancerous conditions.

Effective January 1, 2012, women with qualifying breast or cervical cancer diagnoses,

including specific precancerous conditions, who meet the eligibility criteria for the Breast

and Cervical Cancer Program (BCCP) will be eligible for treatment through BCCTP.

Women no longer need to be diagnosed by a specific BCCP provider, but can be

presumptively enrolled by a licensed health care provider.

The Oregon Breast and Cervical Cancer Program reimburses local medical providers and

tribes throughout the state to administer screening and diagnostic services.

1. Eligibility requirements for BCCTP

There are no financial eligibility requirements for BCCTP once a woman has been

determined by a qualified provider to meet the BCCTP criteria.

To be presumptively eligible for BCCTP, a woman must:

Be an Oregon resident;

Be a U.S. citizen or have lawful residential status;

Have a household income at or below 250 percent FPL;

Have been diagnosed as needing treatment for breast or cervical cancer, or specific

precancerous conditions;

Be under the age of 65;

Be uninsured. She must not have creditable coverage for the needed treatment of

breast or cervical cancer, or precancerous conditions, by health insurance.

Creditable coverage includes:

- Individual or group health insurance;

- Medicare;

- Medicaid;

- Armed forces insurance;

http://www.oregon.gov/DHS/ph/bcc/index.shtml

Medical Assistance Programs J – FSML – 67

J- 2 Breast and Cervical Cancer Treatment Program (BCCTP) October 1, 2012

- Family Health Insurance Assistance Program (FHIAP);

- Oregon Medical Insurance Pool (OMIP).

Not be eligible under any of the mandatory Medicaid programs (MAA, MAF,

Medicaid for pregnant women and children or OSIPM).



2. Application for BCCTP

BCCTP eligibility is determined through the licensed health care provider, and is not

determined by Oregon Health Authority (OHA) eligibility staff.

When an uninsured woman is found to need treatment for either breast or cervical cancer

or precancerous conditions after being screened by a licensed health care provider, the

application process is initiated by the provider.

The Breast and Cervical Cancer Treatment Program (BCCTP) Application and Referral

Form (OHA 1463) is completed by a woman who has been screened by a medical

provider and is found to need treatment for breast or cervical cancer, or precancerous

conditions. The provider assists the woman in completing the patient section of the

application. The provider must also complete and sign the provider section of the

application.

The provider determines the woman to be presumptively eligible for BCCTP and submits

the BCCP application form to the Statewide Processing Center (Branch 5503) to establish

eligibility. If it appears the woman could be eligible for a mandatory Medicaid program,

Branch 5503 will assist the woman in getting an Application Oregon Health Plan and

Healthy Kids (OHP 7210) from the application center. The OHP 7210 will be marked

“BCP” on the label. If a woman submits the OHP 7210 to a branch office, it is to be

forwarded to the Statewide Processing Center.

Note: If a client receiving benefits under another state's Medicaid Breast and Cervical

Cancer Treatment Program is moving to Oregon and inquires about Oregon's

program, refer the client to OHA at 971-673-0581 (staff only) or 877-255-7070

(clients) to ask about the Oregon Breast and Cervical Cancer Treatment

Program. OHA needs direct contact with the client to determine if she meets the

criteria for Oregon's program and to coordinate treatment services, if eligible.

3. Coding

A woman eligible for the BCCTP program will have her case coded as program P2 with a

BCP case descriptor. A woman who has been determined to be presumptively eligible for









FSML – 67 Medical Assistance Programs J –

October 1, 2012 Breast and Cervical Cancer Treatment Program (BCCTP) J - 3

BCCTP but is eligible for another Medicaid program will have her case coded with that

program coding and with a BCS case descriptor.

A woman initially found eligible for BCCTP may be required to complete and return an

OHP 7210 or other Department of Human Services (DHS) application to determine if the

woman is eligible for another Medicaid program. This OHP 7210 application will be

marked “BCP” on the label. If the woman submits the OHP 7210 to a branch office, it

should be forwarded to the Statewide Processing Center.

A woman found eligible for the BCCTP program will have her case coded as program P2

with a BCP case descriptor. If the woman is later determined to be eligible under any of

the mandatory Medicaid programs, her case will be coded with that program coding and

with a BCS case descriptor.

A woman who loses eligibility for another medical program, but has her case coded with

the BCS case descriptor, is still eligible for BCCTP as long as she still needs treatment

and continues to meet all other eligibility requirements for the program.


Household Group (Who is in the household?)

When a woman has been referred for presumptive eligibility based on BCCP eligibility,

the household consists of people who live in the same house, apartment or other dwelling.





commercial room and/or board establishment. When people live in more than one

household during a month, they are considered to be living in the household where they

spend 51 percent or more of their time.


Filing Group (Who must apply together?)

The filing group for BCCTP consists of the individuals from the household group (see

OAR 461-110-0210) whose circumstances are considered in the eligibility determination

process.








Medical Assistance Programs J – FSML – 67

J- 4 Breast and Cervical Cancer Treatment Program (BCCTP) October 1, 2012

Financial Group (Whose income and resources are counted?)




Need Group (What income standard is used?)

For BCCTP, the need group consists of each member of the financial group.

Need Group: 461-110-0630

Benefit Group (Who receives benefits?)

For BCCTP, the benefit group consists of the woman who has been found to be

presumptively eligible for this program.


5. When BCCTP eligibility ends

A woman is no longer eligible for the BCCTP program when:

Her course of treatment has been completed;

She reaches age 65;

She becomes covered for treatment of breast or cervical cancer by creditable

health insurance;

She is no longer a resident of Oregon.

For information regarding the screening and diagnostic services of the Oregon Breast and

Cervical Cancer Program, contact the local county health department or call DHS Health

Services at 971-673-0581. Information about the program can also be found on the

program's Web page at www.healthoregon.org/bcc.

6. Retroactive medical benefits

Clients who are eligible for BCCTP are also potentially eligible for retroactive medical

benefits.






http://www.healthoregon.org/bcc

FSML – 70 Medical Assistance Programs K –

July 1, 2013 CAWEM K - 1

K. CAWEM

The Citizen/Alien-Waived Emergent Medical (CAWEM) program is available to

individuals who meet all the nonfinancial and financial eligibility requirements for a

medical assistance program except for citizen/alien status and Social Security number

requirements. Individuals eligible for CAWEM are only eligible for emergency medical

benefits, including childbirth (labor and delivery) services.

Exception: There is no CAWEM eligibility under the OHP-CHP or HKC category.

The worker does not need to make a decision about whether the person is in need of

emergency medical treatment or childbirth services. Medical decisions are determined by

the person’s medical provider pursuant to the administrative rules of the Office of

Medical Assistance Programs. If a medical provider has questions about whether a

condition is covered, they should contact the Division of Medical Assistance Programs

(DMAP) at 800-336-6016.

CAWEM medical assistance is authorized under the program (BCCTP, MAA, MAF,

EXT, OHP, OSIPM and SAC) for which the person would qualify if they met the

citizen/alien requirement. When benefits are established, CAWEM clients receive a

medical coverage letter stating:

“COVERAGE IS LIMITED TO EMERGENCY MEDICAL SERVICES.

LABOR AND DELIVERY SERVICES FOR PREGNANT WOMEN

ARE CONSIDERED AN EMERGENCY.”

A child born to a CAWEM mother is an assumed eligible newborn (AEN). Add the

child’s medical eligibility to the case using the AEN N/R code.



Most noncitizen children who have legal immigration status but who do not meet the

financial eligibility requirements of a Medicaid or CHIP program are eligible for HKC if

their family income is at or below 301 percent FPL. (Refer to Noncitizens Worker

Guide #1: Noncitizen Charts (NC-WG#1).

Noncitizen children without legal immigration status are not eligible for CHIP or HKC.

Pre-Natal Expansion Program

The CAWEM Pre-Natal Expansion (CWX) Program provides medical services for

pregnant CAWEM clients who reside in one of the participating counties. Currently,

there are 15 counties participating in the CWX program including: Benton, Clackamas,

Columbia, Crook, Deschutes, Douglas, Hood River, Jackson, Jefferson, Lane, Morrow,

Multnomah, Union, Wasco and Umatilla counties.



http://dhsmanuals.hr.state.or.us/EligManual/15ncwg1.htm

Medical Assistance Programs K – FSML – 70

K- 2 CAWEM July 1, 2013

This program was first implemented April 1, 2008, in Multnomah and Deschutes

counties.

The program expanded to Benton, Clackamas, Hood River, Jackson and Lincoln counties

effective October 1, 2009. Lincoln County ended their participation in the program

effective December 4, 2009.

The program then expanded to Lane County effective January 1, 2011.

As of July 1, 2011, Columbia, Crook, Douglas, Jefferson, Morrow, Union, and Wasco

counties were added to the program.

The program then expanded to Umatilla County, effective April 1, 2012.

The program uses OHP-CHP funding to pay for prenatal care. OHP-CHP funds are

permitted for the program because the medical services are limited to prenatal services

and benefit the unborn child, who will be a U.S. citizen at birth:

Any pregnant CAWEM client who resides in the participating counties and meets

the eligibility requirements for a Medicaid program is eligible, regardless of the

Medicaid program used to determine CAWEM eligibility. This would include

MAA CWM, MAF CWM, OPP CWM, etc.;

Only participating county residents who are pregnant CAWEM clients are eligible

for the enhanced benefit package. If the client moves from a participating county

to a county not included in the program area, a timely continuing (10-day) notice

of reduction is required and medical is reduced to CAWEM again;

The enhanced benefit package is a limited version of the OHP Plus benefit

package. Only necessary prenatal services included in the OHP Plus benefit

package will be covered;

Eligibility is tied to the unborn child who will be a U.S. citizen. The mother’s

eligibility for the enhanced benefit package ends when the pregnancy ends. Clients

will receive an automatic CM system notice in the month prior to the DUE N/R

date. The notice will remind the client their plus benefits end the day after the baby

is born;

If the client’s pregnancy ends prior to the month the DUE N/R is coded, reduce

benefits to CAWEM for the first of the month after the 10-day notice period using

notice CMRCWXR or SPRCWXR. Both notices are available on Notice Writer.

Also update the DUE N/R date to reflect the correct month/year the pregnancy

ended;

The pregnant CAWEM client remains CAWEM-eligible during her pregnancy and

for the protected two-month post-partum period. She may receive emergent need

benefits for herself during the pregnancy and for the two months following the end

of her pregnancy;

FSML – 70 Medical Assistance Programs K –

July 1, 2013 CAWEM K - 3

The newborn is an AEN Medicaid eligible child and may receive up to 12 months

protected Medicaid;

There is CM system coding to identify pregnant CAWEM clients in one of the

participating counties. Pregnant CAWEM clients moving into one of the

participating counties will have the coding added to their cases by staff at the OHP

Statewide Processing Center (Branch 5503). Sending branch offices do not need to

add the CM coding.



Medical Assistance Programs K – FSML – 70

K- 4 CAWEM July 1, 2013


FSML – 65A Medical Assistance Programs L – Third-Party Insurance, Health Insurance

May 1, 2012 Premium Payments (HIPP) and Private Health Insurance (PHI) Reimbursements L - 1

L. Third-Party Insurance, Health Insurance Premium Payments (HIPP)

and Private Health Insurance (PHI) Reimbursements

Third-Party Insurance (TPL) – private or employer-sponsored insurance

When a client is identified as having private or employer-sponsored health insurance, it

must be added to MMIS because Medicaid, in most cases, is the payer of last resort.

Other insurance is also known as third-party resources, third-party liability (TPL) and

health care coverage (HCC).

The Health Insurance Group (HIG) verifies third-party insurance policies and then

updates MMIS. HIG also:

Adds a TPL exemption to MMIS so clients with TPL are not auto-enrolled into a

managed health care plan (FCHP or PCO). HIG does not add TPL exemptions for

dental or mental health plans unless they are specifically requested by DMAP.

TPL exemptions only prevent auto-enrollment. They do not prevent manual

enrollment. Before enrolling, workers should check MMIS to be sure clients are

not already enrolled, have an active exemption or have active TPL;

Disenrolls clients from managed health care plans (effective the end of the month

the insurance is identified) when they are determined to have active private or

employer-sponsored health insurance.

If the client is already enrolled in an FCHP or PCO, HIG disenrolls the client from the

plan effective the last day of the month.

MSC 415H – Notification of Other Health Insurance form

Clients are required to report to the department when members of their household who

are receiving or applying for Medicaid have other insurance. This is done by completing

a Notification of Other Health Insurance form (MSC 415H). Once completed by the

client or a worker, the MSC 415H is sent to the Health Insurance Group (HIG). HIG

verifies the insurance with the insurance carrier and updates the TPL file in MMIS. The

MSC 415H should be sent to HIG for new insurance and when existing insurance ends or

changes.

MSC 156 – Request for Rush Verification of Third Party Insurance form

If a client is having an emergency and is unable to get prescriptions or other medical

services due to inaccurate TPL information in MMIS, a worker can request “Rush”

processing by emailing the MSC 156 form to HIG at REFERRALS TPR. In most cases

rush requests are done the same day they are received.

Health Insurance Premium Payment (HIPP)

When a person living in the household has employer-sponsored group health insurance

that covers a household member who is eligible for a medical assistance program (except





https://apps.state.or.us/cf1/DHSforms/Forms/Served/de0156.enabled.pdf

https://apps.state.or.us/cf1/DHSforms/Forms/Served/de0156.enabled.pdf


Medical Assistance Programs L – Third-Party Insurance, Health Insurance FSML – 65A

L- 2 Premium Payments (HIPP) and Private Health Insurance (PHI) Reimbursements May 1, 2012

CEC, OHP-CHP and OHP-OPU), the amount of the health insurance premium payment

(HIPP) paid by the person (not the employer’s share of the cost), may be reimbursed by

the department if it is cost-effective for the state. Self-employed people who have group

health insurance may also be reimbursed if determined cost-effective.

To qualify, the person’s health insurance must be a major medical plan which includes

physician and hospital services, doctor visits, lab and x-ray and pharmacy. Examples of

major medical plans are: a Health Maintenance Organization (HMO); a Preferred

Physicians Care Organization (PCO); a Point of Sale Plan (POS); or an Indemnity Health

Insurance Plan. Examples of what would not be a major medical plan are: Medicare

supplements, accident or replacement policies.

Effective November 1, 2011, eligibility for the HIPP program is determined by the

Health Insurance Group and not the branch offices. This means that workers will not be

able to issue HIPP payments through the CM system, OR ACCESS or using Special Cash

Pay (437). Workers use the MSC 415H to make HIPP referrals to HIG.

For information about the HIPP program including details on the referral process, please

see the DMAP worker guide or contact HIG by email at Reimbursements HIPP or

[email protected].

Payment of Private Health Insurance (PHI)

In special situations, DMAP may pay for insurance premiums even if the premium is

greater than what is allowed on the HIPP Standard Chart. This may occur when the cost

for an individual’s health services is less than the estimated cost of paying for those

services on a fee-for-service (FFS) basis. The Health Insurance Group (HIG) administers

the PHI program and determines program eligibility. HIG may request medical

documentation or copies of Explanation of Benefits (EOBs) before PHI can be approved.

Payments for PHI generally go directly to the insurance carrier; however, in some cases,

payments may be paid directly to the policyholder. The health insurance may be a private

individual family policy or employer-sponsored insurance. The PHI program is for

physical health policies only. The department does not reimburse for dental, vision or

other types of policies under the PHI program.

HIG determines if the PHI premium payment is cost effective by using the HIPP standard

chart and an additional allowance from the Special Conditions Chart.

DMAP does not pay PHI premium payments for:

Non-SSI institutionalized and waivered clients whose income deduction is used for

payment of health insurance premiums;

Clients eligible for HIPP;

Vision, dental or long-term-care policies.

http://dhsforms.hr.state.or.us/Forms/Served/de0415h.pdf

http://www.oregon.gov/OHA/healthplan/data_pubs/wguide/main.shtml



FSML – 65A Medical Assistance Programs L – Third-Party Insurance, Health Insurance

May 1, 2012 Premium Payments (HIPP) and Private Health Insurance (PHI) Reimbursements L - 3

To make a PHI referral, complete Sections 1 through 5 on the Notification of Other

Health Insurance (MSC 415H) form and email it to HIG at Referrals TPR or

[email protected].

Caseworkers and clients are notified if the client has been approved or denied by mail

after the PHI eligibility determination has been made. HIG review PHI cases annually, or

as needed to redetermine eligibility for the program.

SEE DMAP WORKER GUIDE #7 FOR MORE INFORMATION.

Client’s Rights and Responsibilities: 410-120-1855

Payment of Private Insurance Premiums: 410-120-1960

Medical Assignment: 461-120-0315


Clients Required to Obtain Health Care Coverage and Cash Medical Support; CEM, EXT, GAM,

MAA, MAF, OHP (except OHP-CHP), OSIPM, SAC: 461-120-0345

Clients Excused for Good Cause from Compliance with OAR 461-120-0340 and 0345: 461-120-0350

Specific Requirements; Reimbursement of Cost-Effective, Private or Employer-Sponsored Health

Insurance Premiums: 461-135-0990

Changes That Must be Reported: 461-170-0011

Effective Dates; OHP Premium: 461-180-0097





http://www.oregon.gov/OHA/healthplan/data_pubs/wguide/2009/vii-wg.pdf

http://arcweb.sos.state.or.us/pages/rules/oars_400/oar_410/410_tofc.html#120

http://arcweb.sos.state.or.us/pages/rules/oars_400/oar_410/410_tofc.html#120










http://apps.state.or.us/caf/arm/C/461-195-0303.htm

Medical Assistance Programs L – Third-Party Insurance, Health Insurance FSML – 65A

L- 4 Premium Payments (HIPP) and Private Health Insurance (PHI) Reimbursements May 1, 2012


FSML – 65A Medical Assistance Programs M –

May 1, 2012 Types of Decision Notices M - 1

M. Types of Decision Notices

A decision notice is a written notice sent to the benefit group describing the action taken

on an application or redetermination of the benefits.

1. Types of decision notices

There are three types of decision notices that can be given to clients. They are:

A Basic Decision Notice. This notice is mailed no later than the planned date of

action on the case;

A Continuing Benefit Decision Notice. This notice is mailed in time to be received

by the date that benefits are or would be received;

A Timely Continuing Benefit Decision Notice. This notice must be mailed no later

than 10 calendar days before the effective date of the action or 15 calendar days

for clients in the Address Confidentiality Program. Deadlines for 2012 are

included in Multiple Program Worker Guide #18 (MPWG #18).

Medical clients do not always need a notice.

For example, when a child is taken from an MAA family and placed in CW custody,

medical benefits are transitioned from the SSP MAA case to CW medical. There is no

need for the SSP medical worker to send a closure notice as the child has not lost any

medical coverage; the child has just moved from one medical program to another.

Another example of “no notice required” occurs when a client is certified eligible for

OHP and then moves out of the original OHP household. Open the person on their own

OHP medical case for the balance of their original certification. Leave the “sending case”

with the same #OHP need group on the UCMS screen. No notice is required because no

one's benefits were ended or reduced.

No new decision notice is required when a combination eligibility approval and reduction

notice was sent to a child who has been found eligible for a Healthy KidsConnect subsidy

or Healthy Kids employer sponsored insurance reimbursement and who received a

combination approval and reduction notice when the referral was made to the Office of

Private Health Partnerships.


Notice Period: 461-175-0050

2. What a decision notice must contain

A decision notice must do all of the following:




Medical Assistance Programs M – FSML – 65A

M- 2 Types of Decision Notices May 1, 2012

Specify the action (close, reduce, approve), the effective date of the action, the

date the notice is mailed and the reason for the action;

Inform the client of their right to a hearing before an impartial person. This

includes the following:

- Specifying the method and time frame for requesting a hearing;

- Informing the client of their right to representation (including legal

counsel);

- Informing the client about availability of free legal help; and

- Informing the client of their right to have witnesses testify on their behalf.

Cite the administrative rule that supports the action being taken on the case.

Continuing Benefit Decision notices and Timely Continuing Benefit Decision notices

must also inform clients of their right to continuing benefits. Clients are entitled to a

continuation of benefits if they request a hearing by the later of the following:

Within 10 days of the mailing of the notice being contested; OR

On or before the effective date of the action.

What a Decision Notice Must Include: 461-175-0010

3. Medical program notice situations

Send a Basic Decision Notice if:

An application for medical is denied:

Send a Notice of Medical Assistance Program Eligibility Decision (DHS 462A) if

individuals are ineligible for all programs. Send a Notice of Self Sufficiency

Medical Program Eligibility Decision (DHS 462C) if an individual is claiming a

disability and being referred to SPD for a presumptive determination. If some

individuals in a family are approved and others denied, the DHS 462A or

DHS 462C should list the names of those being denied. The date of the notice and

the effective date are the date the eligibility determination is made;

Example 1: Bo put his name on the OHP Standard Reservation List (SRL) and

was sent an application with an OHP 7210P sticker on it. He

completed the application and dropped it off at the local office. He

did not claim to have a disability. The worker checked the SRL and

saw that Bo’s name had not been selected. Bo was ineligible for

any other medical programs, and so the worker sent a DHS 462A.



http://dhsforms.hr.state.or.us/Forms/Served/de0462c.pdf


http://dhsforms.hr.state.or.us/Forms/Served/de0462c.pdf




Example 2: Kevin and Maria are applying for medical assistance for

themselves and their 4-year-old daughter, Alexis. Kevin expects to

earn $200; Maria has a disability and receives $710 in SSD. Alexis

receives $150 in SSB based on her mother’s disability. Maria also

receives Medicare parts A and B. The worker determines that

Kevin is ineligible for any medical programs and Alexis is eligible

for OPC, but thinks Maria may be eligible for QMB. The worker

determines Maria is eligible for QMB BAS and opens the case, but

sends a DHS 462A for Kevin, denying his request for medical

assistance.

An application for medical is denied because of income but is approved for referral

to Healthy KidsConnect;

An application for medical is approved;

Note: The CM system does not automatically send approval notices for retro

MAA/MAF medical. When adding retroactive medical to MAA or MAF

and there is a break in the retroactive medical coverage, send the

GSRETRO approval notice.

The client has been placed in skilled nursing care, intermediate or long-term care;

A client (or another adult filing group member or their authorized representative)

makes a signed written request to withdraw their application or end their benefits;

The client is placed in official custody or a correctional facility. End medical

benefits the end of the calendar month;

The client's mail has been returned and their whereabouts are unknown. Send a

basic decision notice to their last known address. If the client's whereabouts

become known during the benefit month, restore benefits;

A client has moved out of state and becomes eligible for benefits in another state.

Notice Situations; General Information: 461-175-0200

Notice Situation; Client Moved or Whereabouts Unknown: 461-175-0210

Notice Situation; Nonstandard Living Situations: 461-175-0230

Notice Situation; Removing an Individual From a Benefit Group (EXT, MAA, MAF, OHP, REF, REFM,

SAC, SNAP, TANF) or Need Group (ERDC): 461-175-0305

Notice Situation; Voluntary Action: 461-175-0340

Effective dates; Suspending or Closing Benefits and JOBS Support Service Payments: 461-180-0050

Send a Timely Continuing Benefit Decision notice if:

Benefits are reduced or closed.

Note: Except in the case of a person fraudulently getting medical assistance, determine

eligibility for any other medical programs prior to ending benefits. If an










individual becomes ineligible for a program but claims a disability that meets the

criteria for a presumptive referral, make the referral and leave the case open until

SPD makes a presumptive determination. After eligibility for all other programs

has been determined, send a timely, 10-day notice and a DHS 462A prior to

reducing or closing medical assistance.

Example 1: Ken’s OHP certification was set to expire in March. On his

DHS 945 pend form he reported that he married Barb, who earns

$1,300 a month, and that he has a disability. Based on the income,

the worker determines Ken is no longer eligible for OHP, but the

income is below OSIPM standards after allowable deductions.

After a discussion with Ken, the worker determines his disability

meets the criteria for a presumptive referral to SPD and completes

the referral, extending the BED coding to allow time for SPD to

make a decision. On June 15, SPD determines Ken’s disability

does not meet the requirements for OSIPM and Ken is sent an

SDS 540 and DHS 462A. SPD notifies the branch of his

ineligibility. Since Barb’s income continues to be over the OHP

standard, Ken is sent a timely notice citing income as the reason

for his ineligibility for OHP. There is no need to send a DHS 462A

because SPD has already sent a notice stating that he does not

qualify for any medical programs.

Example 2: Ellie completed and turned in her DHS 945 for OHP. The worker

noted there was still information that was needed to determine

eligibility and sent another pend. The client did not return the

requested verifications in the 45-day processing time frame. Based

on the BED date, a timely continuing benefit decision notice (77B)

is automatically sent and the case automatically closed effective

the last of the month following notice.

Example 3: Kevin is an adult who has been receiving OHP. On March 10 he

reported that he began receiving Medicare Parts A and B. The

worker determines that he is eligible for QMB BAS and converts

his case to QMB for April 1. The worker sends the Notice Writer

notice, CMR2QMB parts 1 and 2.

Benefits are closed but the child is referred to the Office of Private Health

Partnerships for the Healthy KidsConnect full buy-in program;

The client has moved out of state and the client is not eligible for benefits in the

other state;

Client was receiving a Health Insurance Payment (HIPP) reimbursement and then

the private health insurance ends. Client is no longer eligible for the HIPP

reimbursement;

A change affecting eligibility is reported and medical must be reduced or closed.



http://dhsforms.hr.state.or.us/Forms/Served/sw0540.pdf






Example 1: Suzy and her son Timmy are receiving OHP. Suzy calls her worker

to report that her son, Timmy has moved to Texas to live with his

father. Send a timely continuing benefit decision notice to close

Timmy's OHP benefits effective the first of the month following

notice.

Example 2: Stan and his son were receiving MAA medical. Stan reports he

married Susan and when the eligibility worker redetermines

eligibility, Stan and his son are over the MAA income limits based

on Susan's income. Stan is not eligible for any medical program,

but his son is eligible for CHP. Send a timely continuing benefit

decision notice to close Stan's benefits for the first of the month

following the notice.

Example 3: Child Welfare contacts the CAF worker to tell them they removed

the only child from an MAA household. Worker redetermines

eligibility for the adult on the case, and finds them eligible for

OHP-OPU. Send a timely continuing benefit decision notice

(DHS 462R) and reduce the benefits for the first of the month

following notice.

Notice Situations; General Information: 461-175-0200

Notice Situation; Client Moved or Whereabouts Unknown: 461-175-0210

Notice Situation; Removing an Individual From a Benefit Group (EXT, MAA, MAF, OHP, REF, REFM,

SAC, SNAP, TANF) or Need Group (ERDC): 461-175-0305

Notice Situation; Voluntary Action: 461-175-0340

https://apps.state.or.us/cf1/DHSforms/Forms/Served/DE0462R.pdf





FSML - 64 MA-WG #1

January 1, 2012 Client Maintenance System Medical Reports Page - 1

Worker Guide

Client Maintenance System Medical Reports

Multiple programs reports:

WBE0035R-A CMS/BENDEX Cross File Discrepancy List

Lists discrepancies between SSB information on CM case and

BEIN screen data.

WBE0035R-C MMIS/BENDEX Cross File Discrepancy List

Lists discrepancies between SSA information on CM case and

BEIN screen data.

WCMSPECR-A Client Maintenance Special One-Time Report

Special reports not expected to be needed over a long period of

time.

WCM0345R-B Client Mid-Month Notices/JOBS Notices

Lists CM-generated timely continuing notices and informational

notices.

WCM0390R-A Medical Review/Deliver Coming Due

WCM0390R-C Medical Review/Delivery Due or Overdue

WCM0390R-E Redeterminations Coming Due

WCM0390R-F Redeterminations to Be Mailed Next Month

WCM0390R-G Redeterminations Due or Overdue

WCM0390R-P Redeterminations Due/Send Alternate Format

WCM0472R-C Oral Presentation 943Q Alternate Format Report

Lists clients sent the DHS 943 “Change Report” form needing

an oral presentation of the form.

WCM0520R-A P2, 2 & 82 Cases by Street Address

WCM3165R-Q Monthly List of Persons Turning 65 in 3 Months

WCM3166R-A Alphabetical Listing of CMS Cases

WCM3175R-V CMS/SDX Discrepancy Report

Lists discrepancies between SSI information on CM case and

BEIN screen data.

WCM3405R-A Child Count by Age and Program for Case Stat CP/VP

WCM3445R-A Adult Count by Age and Program for Case Stat CP/VP

WCM3455R-A Report of Cases for Review

WCM4100R-C Health Care Premium Reimbursement Payments Report

WCM4235R-C CMS Check Cancel Report

Includes Medical Care IDs

WCM4316R-A Parents W/No Medical But Have Children Under 19 W/Medical

WCM4360R-A List of Cases with BED N/R

WCM5125R-B CMS Cases with Alternate Format by Branch and Worker

WCM5125R-C CMS Cases with Alternate Format by Alternate Format

WCM5125R-D CMS Cases with Alternate Format by Case Name

WCM5125R-E CMS Cases with Alternate Format by Language and Alternate

Format

WCM5125R-F CMS Cases CNT of Households by Language within Branch,

then Summary

WCM5155X-A Monthly Medicaid Active Sampling

WSV0085R-A TPQY Report of SSNs Unverified by SSA

http://dhsforms.hr.state.or.us/Forms/Served/DE0943.pdf

MA-WG #1 FSML - 64

Page - 2 Client Maintenance System Medical Reports January 1, 2012

OHP reports:

WCM4050R-C Monthly List of PLM/OH2 Children Turning 6

WCM4280R-A Detail Listing of CP/VP OHP Cases with Income $2,000 or

More All Incomes Included

WCM4315R-A List of Cases Denied OHP2

Lists online OHP2 denials by branch, worker and FPL

percentage.

WCM4325R-A Persons with OAP Need Resource for Month

WCM6100R-A Cases with STD N/R Needing Review

WCM6200R-A Case Transfers from 5503 to SPD Branches

WCM6200R-B Case Transfers from 5503 to CAF Branches

Breast and Cervical Cancer Program reports:

WCM0345R-E Client Maintenance BCP Generated Client Notice 53B

WCM0390R-Q BCP Redetermination Coming Due

WCM0390R-R BCP Redetermination Due or Past Due

WCM4050R-F List of BCS Cases Closures for MM/CCYY

COLA reports:

WBE0235R-B Garnishments – Client Maintenance CP/VP/NA Cases

WCM1015R-A No BENDEX Record – SSB Increased by COLA Percent

WCM9204R-A Annual OSIP/GA Standards Increase – Cases Going NA

WCM9205R-A Cases with Other N/R Codes

FSML – 70 MA-WG #2

July 1, 2013 OHP Quick Reference Guide Page - 1

Worker Guide

OHP Quick Reference Guide

OHP Categories

CHP CHIP child under age 6, from 133% to 201%

FPL. From 6 to under age 19, 100% up to 201% FPL.

OP6 Child under age 6, from 100% up to 133% FPL.

OPC Child under age 19, up to 100% FPL.

OPP Pregnant women of any age up to 185% FPL.

OPU Non-pregnant age 19 and older, up to 100%

FPL.

Other OHP Related CM Case Descriptors

ADA Approved for an ADA accommodation.

CID Denied or closed; did not provide acceptable

citizenship verification.

CIE Pend extended for acceptable citizenship

verification.

CIP Pending acceptable citizenship verification.

CWM CAWEM; Eligible for emergency services only.

CWX Pre-Natal CAWEM Expansion Program pilot.

FHP Not medically eligible; receiving FHIAP.

HNA Client has Native American/Alaska Native

status.

NOD Denied or closed, did not provide noncitizen

documentation.

NOE Pend extended for noncitizen documentation.

NOP Pending noncitizen documentation.

OHS OHP eligible full-time student.

OHP Program CM Need/Resource Items

AEN Tracks assumed eligible newborn eligibility.

CDU Tracks CHIP pregnant women DUE date

CHP End of CHP certification.

CIE End of extended citizenship pend

CIP End date of citizenship pend.

ESP With month/year date, ESP tracks ESI

availability date for OPU clients. With “C”

continuous date, ESP identifies HKC subsidy

clients with available ESI.

DUE Tracks pregnant woman’s due date.

HIP Approves cost-effective ESI reimbursements.

HPI Identifies income used for OHP eligibility.

LPR Beginning of five-year LPR period (for adults

and children).

NCS Non-LPR, non-REF noncitizen who meets alien

status

NOE Pend extended for noncitizen documentation.

NOP Pending noncitizen documentation.

OPC End of OPC certification.

OP6 End of OP6 certification.

STD Determines end of OPU certification period.

Citizen/Noncitizen Status

US citizen or approved noncitizen 461-120-0110

Must sign citizen/noncitizen statement 461-120-0130

SSN

Except for CWMs and AENs 461-120-0210

Pursuing and Assigning Benefits/Assets

Client must pursue and assign health 461-120-0345

insurance and other third-party resource, 461-120-0315

unless good cause 461-120-0350

Except for good cause client must pursue

medical support 461-120-0350

CHP and OPU clients cannot get HIP 461-135-1100

Specific Requirements

Must be ineligible for Medicare (unless

pregnant) and Plus benefit package

medical 461-135-1100

OPU must not have private major medical

or have had medical for the past 6 months

unless waived 461-135-1100

CHIP must not have medical or have had

medical for the past 2 months unless

waived 461-135-1100

Resource Limits

$2,000 for OPU

No resource limit for other OHP 461-160-0015

Income Limits

Countable income must be below the OHP

limits 461-155-0225

Age

OHP age requirements 461-120-0510

OPU

Applicants must be transitioning from a

medical program that provides the OHP

PLUS benefit package; or

Have been continuously eligible for OPU; or

Have been randomly selected from the

reservation list 461-135-1102

461-135-1125

Some OPU clients must pay premiums 461-135-1120

Exempt if HPI less than or = 10% FPL at

recertification. 461-135-1120

Exempt if CAWEM or verified Native

American/Alaska Natives 461-135-1120

Uninsured for 6 months, unless waived 461-135-1100

Exempt from copays 410-120-1235

Have a different benefit package 410-120-1210

Native American/Alaska Native (HNA)

“HNA” means the client is a tribal member or eligible for

Indian Bureau Health benefits.

Verify Native American/Alaskan Native status. Once verified

and the HNA case descriptor is added to the CM case, the case

descriptor may not be removed.

Do not have to pay copays.

Do not have to pay OHP premiums.

Have the option of selecting a Managed Health Care plan.

If OPU (and not CAWEM), receive the standard benefit

package.

Processing OHP Standard Reservation List Applications

SPD/AAA offices process OHP Standard Reservation List

application if the applicant is age 60 and above.

If there is no companion case, Branch 5503 processes the

application

Certification Period

Effective March 1 DOR and later, all OHP categories have

12-month certification periods.

New applicants: do not count DOR month toward 12-month

certification. Open effective DOR (if eligible on that date) and

certify through the next 12 months..

OHP Eligibility Requirements

OHP Program Quick Reference Guide

March 2011





















http://arcweb.sos.state.or.us/rules/OARS_400/OAR_410/410_tofc.html#120

http://arcweb.sos.state.or.us/rules/OARS_400/OAR_410/410_tofc.html#120

MA-WG #2 FSML – 70

Page - 2 OHP Quick Reference Guide July 1, 2013

OHP Premium Status Codes

The Premium Status displays on each OPU client’s CI-FIND

screen and on UCMS when certifying the case.

C Current.

I Initial. Status not updated by OHP Premium Billing

Office.

K Arrearage of OHP2 premiums.

OHP Premium Payment Requirements

OPU clients applying for OPU may be responsible for

paying premiums, including past due premiums.

OPU clients are exempt if CWM, HNA or their HPI

income at recertification is 10% or less of the FPL.

If exempt, code the Waiv field on UCMS with “WE.” All

past billed premiums will be automatically removed (you

do not need to adjust them manually on MMIS).

To bypass the K edits on UCMS, enter “CD” in WAIV.

Due Process Coding and Notices

Do not let benefits end if the client has established a DOR.

Add the Bypass End Date (BED) coding to prevent the

automatic closure; i.e., we no longer deny at recertification,

instead we close the case if no longer eligible.

The BED end date should provide long enough to get any

needed pended items and/or the 10-day close notice.

If ineligible for ongoing benefits, send the appropriate

close notice (over income, over resource, etc.) and also

send the DHS 462A.

For new OPU applicants, send just the DHS 462A notice.

OHP CM Reason Codes and Notices

DB CHP; Ineligible Noncitizen

DD OHP; 45 Day Limit

DF OPU; Premium Past Due

DM OHP; Eligible for Medicare

DN OPU; OPU Receiving Major Medical

DO OHP; Over Income

DP OHP; Resident of Public Institution

DR OHP; Does Not Meet Residence Requirements

DU OHP; Unable to Locate

DW Close Medicaid: Did not Verify Citizenship

DX OHP; Resources Exceed Limits

OHP CM Approval Notices

1F Health Insurance Premium Reimbursement

Approved (HIP)

1K OHP Program- OPC /OP6/CHIP/OPP Approved

2K OHP Program - OHP Standard Approved

3K OHP Program – CAWEM OPC/OP6/OPP Approved

4K OHP Program - CAWEM OPU Approved

5K Pregnant CHIP Approved

Mid-Month OHP CM Notices (mailed about the 15th)

23B Health Insurance Sign-up – Advance (HIP)

24B Health Insurance Not Elected – Benefits End (HIP)

25B Health Insurance Premium Reimbursement Ending

33B* OHP Period Ends – Advance Notice (SSP)

34B* OHP Period Ends – Final Notice (SSP)

35B Notice to Apply for Medicare

36B Medicare Eligible, OHP ends (when OHP recipient

turns 65)

38B OHP child Removed at 19 – Advance Notice

40B OHP Period Ends – Advance Notice (SDSD)

41B OHP Period Ends – Benefits End (SDSD)

50B OHP Closes; Age 6 at 133% Level

52B OHP Closes; Age 1 at 185% (AENs)

58B OHP; Available Employer Sponsored Insurance –

Final

59B OHP Child Removed at Age 19 Final Notice

74B* OHP Closes; Pregnancy Ends – Advance

75B Medical; 19 Year Old Must Apply for Medical -

Advance

76B Medical; 19 Year Old Must Apply for Medical – Final

77B Eligibility/Review/Verification Not Completed

89B Pregnant CHIP Period Ends – Advance Notice

90B Pregnant CHIP Period Ends – Final Notice

*Notices are not sent when the DHS 945 medical pend form

is mailed a redetermination.

OHP NOTR Notices

CMAD2RL Added to Reserve List ; OHP Standard

CMCAREC Due Process Close At Recertification; OHP

CMCITPD Pend Medical; Proof of Citizenship

CMCITST Medical; Citizen/Alien Status Met

CMCOHOM OHP; Medicare Begins, Close

CMCOHPC OHP/CHP; Major Medical Begins; Close

CMCOHST OHP; Ineligible Student

CMC0FHP OHP; Close, No Coop w/FHIAP

CMC0OPP OPP Closes; Pregnancy Ends

CMC2FHP OHP; End Medical, FHIAP Begins

CMD0ARR OHP; Deny – Premium Past Due

CMD0CAW OHP; Not Eligible Except for CAWEM

CMC00CL Unable to Locate or Other State Benefits –

Close

CMC00CR Eligibility Review \/Verif Not Done – Close

CMC00DU Unable to Locate – Deny

CMC00DW Close Medical; Didn’t Verify Citizenship

CMC0NSB Moved to Other State – Close

CMD00DT Deny Medical; Did not Verify Citizenship

CMDODEN OHP; OHP Medical Denial Notice

CMDOPUO OPU; Over Income

CMDOHPM OPU, CHP; Deny – Private Health Insurance

CMMED01 Not Eligible for Med-Related Travel Pymt

CMMEDTR Notice of Transfer

CMMHCEN Medical; Medical Approved – Enrolled

CMNCSPD Proof of INS Status

CMOHP01 Notice of Transfer – OHP

CMOPHEN OHP; OHP Approved, Enroll in Plan

CMR0FHP OHP; Reduce, No Coop w/FHIAP

CMR2STD Reduce Benefits to Standard

CM462A1 Deny or Close Medical Eligibility, Part 1

CM462A2 Deny or Close Medical Eligibility, Part 2

CM462C1 Deny or Close SSP Medical Eligibility, Part 1

CM462C2 Deny or Close SSP Medical Eligibility, Part 2

GSMAPRV Medical Benefits Approved

GSM210A 210A Medical Only Pend

GS00210 Notice of Pending Status

GSOH210 OHP Notice of Pending Status

GSO211 OHP Health Plan Choice

DMAP Client Services Unit: 1-800-273-0557

OHP Premium Billing Office: 1-888-647-2729

PO Box 1120 TTY: 1-866-203-8931

Baker City, OR 97814

OHP Central Processing Branch: 1-800-699-9075

OHP Standard Reservation List: 1-800-699-9075

Faxes: 503-373-7866

503-378-6295

GroupWise: reservation, standard

OHP Program Analysts: SSP-Policy, Medical

Joyce Clarkson 503-945-6106

Michelle Mack 503-947-5129

Carol Berg 503-945-6072

Vonda Daniels 541-690-6139

Christy Garland 503-947-5519 or 541-684-2344

Jewell Kallstrom 503-947-2316 or 503-269-0610

OHP Notices

Resources

OHP Premium Requirements

http://dhsforms.hr.state.or.us/Forms/Served/DE0462A.pdf

http://dhsforms.hr.state.or.us/Forms/Served/DE0462A.pdf

FSML – 59B MA-WG #3 December 1, 2010 Citizenship and Identity Documentation Hierarchical List Page - 1

Worker Guide Citizenship and Identity Documentation Hierarchical List

Clients should not need to verify citizenship more than once. Before requesting documentation, check the Medicaid or CHIP

applicant or recipient’s citizenship field on Person/Alias Update. If the person’s citizenship field already has an “A” and you have no reason to doubt the “A” is accurate, narrate the citizenship documentation has already been verified.

Accept secondary documentation if primary is available within 45 days but secondary is already available. For example, for

persons born in Oregon, secondary documentation is already available via BBCN. Do not pend for primary.

If it is determined that the client cannot obtain a higher-level citizenship documentation within 45 days from the DOR, accept lower level documentation. Do not pend for higher-level documentation.

Citizenship (including identity) documents may be expired and still be used for documentation. Use prudent person; if you

cannot tell it is the same person, pend for other documentation.

The client must provide an original or certified copy of the documentation. The local DHS office must maintain a copy of the documentation in the case record except for BBCN. Do not print BBCN screens.

If another state has already verified citizenship and identity of an applicant per federal requirements, accept the copies of

verification from the other state Medicaid or CHIP office, narrate, and update the CI Person/Alias Update screen. If the other state is unable to send copies of the verification they used, we can take a written statement on their state letterhead or on an e-mail from the state government office.

A document issued by a federally recognized Indian tribe, such as a tribal enrollment card or certificate of degree of Indian

blood is now acceptable verification of U.S. citizenship, as long as the tribe is located within the States. We are waiting for federal guidance for tribes with international borders.

Do not deny or delay Medicaid or CHIP medical benefits to an otherwise eligible applicant pending the verification of the

individual's citizenship documentation. However, if a client who is required to provide citizenship documentation does not provide the necessary documentation within the time allowed, and does not request an extension, medical benefits must be closed with a timely continuing benefit notice.

MA-WG #3 FSML – 59B Page - 2 Citizenship and Identity Documentation Hierarchical List December 1, 2010

1. Citizenship Documentation Requirements

Primary Documentation Primary documents are considered the most reliable and may be used for both citizenship and identity.

Additional Clarifications/Examples

• U.S. passport. Spouses and children were sometimes included on one passport through 1980.

• Certificate of Naturalization (N-550 or N-570). The Department of Homeland Security issues the Certificates of Naturalization and the Certifications of Citizenship.

• Certificate of Citizenship (N-560 or N-561). The Department of Homeland Security issues certificates of citizenship to individuals who derive citizenship through a parent.


Secondary Documentation Second-level citizenship documents do not verify identity. When using second level, document both citizenship and identity.


• A U.S. public birth certificate issued by the State, Commonwealth, Territory, or local jurisdiction issued before the child was 5 years of age and showing birth in one of the 50 U.S. States, District of Columbia, Puerto Rico1, Guam (on or after April 10, 1899), Virgin Islands of the U.S. (if born on or after January 17, 1917)2, American Samoa, Swain’s Island, Northern Mariana Islands (after November 4, 1986 (NMI local time)).3

An amended birth certificate that is amended after five years of age is considered fourth-level evidence of citizenship.

BBCN is considered the same as a birth certificate. Do not print the BBCN screen, even for hearings. If another state mails us screen prints verifying birth certificate information, we can accept it and also consider it the same as a birth certificate. It must be mailed, not faxed.

Adopted children on BBCN born in another country have not met the citizenship requirements; they must be verified with the Department of Homeland Security.

• Most birth certificates are certified copies of the original. Depending upon the age of the document, Oregon birth certificates may say something like “I hereby certify that the foregoing copy has been compared with the original” and may have the state registrar’s signature.

1 Puerto Rico

• New applicants who have not verified their citizenship prior to November 1, 2010, must provide birth certificates issued after July 1, 2010. Applicants who verified their citizenship with Puerto Rican birth certificates prior to November 1, 2010, do not need to re-verify their citizenship.

• Collective Naturalization: Evidence of birth in Puerto Rico on or after April 11, 1899, and the applicant’s statement he or she was residing in the U.S., a U.S. possession, or Puerto Rico on January 13, 1941 – or – Evidence the applicant was a Puerto Rican citizen and the applicant’s statement he or she was residing in Puerto Rico on March 1, 1917, and he or she did not take an oath of allegiance to Spain.

2 Virgin Islands of the U.S. • Collective Naturalization: Evidence of birth in the U.S. Virgin Islands and the applicant’s statement of residence in the U.S., a U.S. possession, or the U.S. Virgin

Islands on February 25, 1927 – or – Applicant’s statement indicating residence in the U.S. Virgin Islands as a Danish citizen on January 17, 1917, and residence in the U.S., a U.S. possession, or the U.S. Virgin Islands on February 25, 1927, and he or she did not make a declaration to maintain Danish citizenship – or – Evidence of birth in the U.S. Virgin Islands and the applicant’s statement indicating residence in the U.S., a U.S. possession or Territory, or the Canal Zone on June 28, 1932.

3 Northern Mariana Islands (NMI) (formerly part of the Trust Territory of the Pacific Islands (TTPI)) • Collective Naturalization: Evidence of birth in the NMI, TTPI citizenship, and residence in the NMI, the U.S., or the U.S. Territory or possession on November 3,

1986 (NMI local time), and the applicant’s statement that he or she did not owe allegiance to a foreign state on November 4, 1986 (NMI local time) – or – Evidence of TTPI citizenship, continuous residence in the NMI since before November 3, 1981 (NMI local time), voter registration prior to January 1, 1975, and the applicant’s statement that he or she did not owe allegiance to a foreign state on November 4, 1986 (NMI local time) – or – Evidence of continuous domicile in the NMI since before January 1, 1974, and the applicant’s statement that he or she did not owe allegiance to a foreign state on November 4, 1986 (NMI local time).

Note: If a person entered the NMI as a nonimmigrant and lived in the NMI since January 1, 1974, this does not constitute continuous domicile and the individual is not a U.S. citizen.


Secondary Documentation Second-level citizenship documents do not verify identity. When using second level, document both citizenship and identity.


• Certification of Report of Birth (DS-1350). The Department of State issues a DS-1350 to U.S. citizens in the U.S. who were born outside the U.S. and acquired the U.S. citizenship at birth, based on the information shown on the FS-240. When the birth was recorded as a Consular Report of Birth (FS-240), certified copies of the Certification of Report of Birth Abroad (DS-1350) can be issued by the Department of State in Washington, D.C. The DS-1350 contains the same information as that on the current version of Consular Report of Birth FS-240. The DS-1350 is not issued outside the U.S.

• Many states issue debit-card-sized “true abstracts” of the original birth record. Oregon used to issue them, but stopped several years ago. Accept as second level documentation.

• Consular Report of Birth Abroad of a U.S. Citizen (FS-240). The Consular Report of Birth can be prepared only at an American consular office overseas while the child is under the age of 18. Children born outside the U.S. to U.S. military personnel usually have one of these.

• Certificate of Birth Abroad (FS-545). • U.S. Citizen Identification Card (I-197) or the prior version I-179. • American Indian Card (I-872) for the Texas Band of Kickapoos. • American Indian tribal enrollment card or certification of degree of Indian blood. Must be for a

tribe located within the U.S. • Northern Mariana Card (I-873). • Final adoption decree showing child’s name and U.S. place of birth.

The adoption decree must show the child’s name and U.S. place of birth. • Evidence of U.S. Civil Service before June 1, 1976 (individuals employed by the U.S. Civil Service

prior to June 1, 1976, had to be U.S. citizens). • U.S. Military Record showing U.S. place of birth. • Verification with Department of Homeland Security’s Systematic Alien Verification for Entitlements (SAVE) database for naturalized citizens. • LPR Child under age 18 of a Naturalized citizen.

If an LPR child of a naturalized citizen does not have his/her own citizenship documentation, verification of the child’s LPR status AND their parent’s naturalization meets the citizenship documentation requirements for the child.


Third Level Third-level citizenship documents do not verify identity. When using third level, document both citizenship and identity.


• Extract of hospital record on hospital letterhead established at the time of the person’s birth. Includes hospital records usually considered “souvenirs” such as footprint records, but ONLY if the record includes the name, DOB, city/state of birth, and has the hospital logo, or is on letterhead or has the signature of a hospital official.

Must have been created at least five years before the initial application date. For children under 16, it must have been created near the time of birth or 5 years before the date of application.

• Religious record recorded in the U.S. within three months of birth showing the birth occurred in the U.S. and showing either the date of the birth or the individual’s age at the time the record was made. The record must be an official record recorded with the religious organization. (Entries in a family bible are not considered religious records). • Early school record showing a U.S. place of birth. The school record must show the name of the child, the date of admission to the school, the date of birth, a U.S. place of birth, and the name(s) and place(s) of birth of the applicant’s parents. • Life, health, or other insurance record that was created at least five years before the application date and indicates a U.S. place of birth. For children under 16, it must have been created near the time of birth or five years before the date of application.


Fourth Level Fourth-level citizenship documents do not verify identity. When using fourth level, document both citizenship and identity.


• Federal or state census record showing U.S. citizenship or a U.S. place of birth. The census record must also show the client’s age. To secure information from census records from 1900 through 1950, Form BC-600 is available.

Note: The ‘affidavit of

citizenship’ cannot be used with the ‘statement of identity’.

• One of the following documents if created at least five years before the application for Medicaid and it includes U.S. place of birth (for children under 16, it must have been created near the time of birth or five years before the date of application):

Seneca Indian tribal census record. Bureau of Indian Affairs tribal census records of the Navaho Indians. U.S. State Vital Statistics official notification of birth registration. A delayed U.S. public birth record recorded more than five years after the person’s birth. Statement signed by the physician or midwife who was in attendance at the time of birth. Bureau of Indian Affairs Roll of Alaska Natives.

• Institutional admission papers from a nursing home, skilled care facility, or other institution that was created at least five years before the initial application date and shows a U.S. place of birth.

Institutional admission papers generally show biographical information for the person. If the record shows a place of birth it can be used to establish citizenship.

• Medical (clinic, doctor, or hospital) record created at least five years before the initial application date and indicates a U.S. place of birth.

Medical records generally show biographical information for the person. If the record shows a place of birth it can be used to establish citizenship.

Note: Immunization records cannot be used. For children under 16, the document must have been created near the time of birth or 5 years before the date of application.

• Written Affidavit, used only in rare circumstances. Affidavits by two individuals (one who is not related to the applicant) who can establish their own citizenship and identity (according to this policy) and who have personal knowledge of the event(s) establishing the applicant’s or recipient’s claim of citizenship, and an affidavit from the client or other knowledgeable individual explaining why documentary evidence does not exist or cannot be readily obtained.

• Naturalized citizens can now utilize the affidavit process.


2. Identity Documentation Requirements

Evidence of Identity • Certificate of Degree of Indian Blood, or other U.S. American Indian/Alaskan Native tribal

document with a photograph or other personal identifying information relating to the individual. Acceptable if the document carries a photograph of the applicant or recipient, or has other personal identifying information relating to the individual.

• Do not accept voter registration cards or Canadian driver’s licenses.

• The SNAP head of household’s

identification verification (including photocopied documents) may also be used to meet the citizenship identification requirement. This applies ONLY to the head of household on the SNAP case.

• JJIS (Oregon’s Juvenile Justice computer system) records may be used for identification.

• JOB Corps is a federal agency.

They have the authority to copy and send the JOB Corps ID they issue to their recipients. DHS can accept this ID as a certified copy by an issuing agency when it is mailed to us directly from a JOB Corps office.

• Any identity document described below: Driver’s license issued by state or territory either with a photograph of the individual or other identifying information of the individual such as name, age, sex, race, height, weight, or eye color.

School identification card with a photograph of the individual. U.S. military card or draft record. Identification card issued by the federal, state, or local government with the same information included on driver’s licenses.

Military dependent’s identification card. Native American tribal document. U.S. Coast Guard merchant mariner card. Data matches with other agencies. Department of Motor Vehicles (DMV) data provided on WVIR screen meets the federal guidelines for acceptable documentation for a client’s identity.

Fishing and hunting licenses issued by the State of Oregon. Three or more corroborating documents such as marriage licenses, divorce decrees, high school diplomas, and employer ID cards to verify the identity of an individual (only to be used if applicant submitted second or third tier—not fourth tier citizenship documentation).

• For Children who are under 16, when the child does not have or cannot get any document above: School records (including report cards) that show date and place of birth and parent(s) name. School records may include nursery or day care records showing date and place of birth, but they must be verified with the issuing school.

Clinic, doctor, or hospital record can be accepted. For children up to 16 years of age (or up to age 18 in very limited circumstances), an affidavit signed under penalty of perjury by parent or guardian attesting to the child’s identity. An affidavit must state the date and place of the birth of the child and cannot be used if an affidavit for citizenship was provided.

Note: The 415F application and the OHP 7210 application have been revised to include information about the place of birth for each applicant. If the parent/guardian completes the place of birth and relationship for each child applicant and signs the application, this replaces the Statement of Identity for Children Under 16 Years of Age (DHS 694). The DHS 694, the 415F, or the OHP 7210 can also be used as an identity statement for children up to age 18 when nothing else is available.

• The identity affidavit can also be used for disabled individuals in residential care facilities.

FSML – 64 MA-WG #4 January 1, 2012 SSP Medical Program Incarceration Policy & Coding Matrix Page - 1

SSP Medical Program Incarceration Policy & Coding Matrix A unit in OPAR is responsible for suspending (ending) OHP medical benefits when the client is incarcerated with an anticipated

incarceration period of a year or less. OPAR also closes the companion SNAP case if the inmate is the only person on the case. OPAR will notify the branch if it‟s necessary to take any additional action.

If necessary to suspend (end) medical benefits, send a Basic Decision Notice such as the CMC00IN/SPC00IN; close medical effective the date the notice is mailed.

“Suspending” benefits means that released inmate‟s SSP medical may be restored without a redetermination, but only if released from

prison/jail within 12 months AND their release was reported within 10 days. If they do not report their release timely, determine if the former inmate (“releasee”) has good cause for reporting late. If good cause, treat as if reported timely and restore SSP medical

benefits without a redetermination. (You may need to redetermine after restoring benefits. See the examples below).

There is new coding to support the inmate suspension process. The “DOC” N/R and C/D coding tracks SSP medical program clients whose medical has been suspended because of their incarceration. The “DOC” N/R end date is a year from the month the client was incarcerated. For example, a client is incarcerated in June; the DOC end date is June of the following year.

When medical is restored for a releasee, the DOC N/R and C/D should remain on the case.

What to Do When an SSP Medical

Program Client is Incarcerated What to Do When the Client is Released

& Reports Timely

What to Do when the Client is Released from

Incarceration and Does NOT Report Timely

Example 1: Individual on OHP case alone

is incarcerated.

When an SSP medical program client is incarcerated, we must suspend the medical. Enter a SUSPEND on the UCMS screen, effective the same date on the basic decision notice. On CMUP, add the DOC C/D and N/R.

Reopen his/her OHP medical for remainder of most current certification period.

If a redetermination occurred while incarcerated, BED the case and redetermine medical immediately.

Determine if good cause exists for not reporting timely.

If good cause exists for late reporting, restore medical, effective the date the client says they were released from incarceration.

If no good cause exists, provide information for the OHP SRL and review for all other medical programs.

MA-WG #4 FSML – 64 Page - 2 SSP Medical Program Incarceration Policy & Coding Matrix January 1, 2012



& Reports Timely



Example 2: Individual in an MAA

household is incarcerated. Because the system will not support a „SUSPEND‟

action with others on the case, close inmate‟s medical on the CM system.

Enter a MEDI action on the UCMS screen and end the inmate‟s medical on CMUP. On CMUP, end the inmate‟s medical. Add a DOC C/D and DOC N/R with end date of a year from the date of incarceration.

Family will continue on MAA if still eligible.

Restore to the same medical program the releasee had prior to incarceration, even if the rest of the family is now on another medical program.

The effective date for reopening medical is the date the inmate states he/she was released.

Example: If the releasee had been receiving MAA, restore to MAA even if the rest of the family has since moved to OHP or EXT. BED the case and redetermine eligibility for the entire filing group.

Determine if good cause exists for not reporting the release timely.

If good cause exists, restore medical, and redetermine for entire filing group. Effective date for restoring the medical would be the date the clients says they were released from incarceration.

If no good cause, do not restore medical. Treat the date they reported the release to the branch as a new DOR, and determine eligibility for releasee and entire family. Provide information about the OHP Standard Reservation List (SRL).

Example 3: Individual on MAA or OHP

with family, but the inmate is not

expected to return to household due to

DV or other reasons.

Remove the inmate from the family OHP or MAA case. Set up new case for inmate and open on same medical program. The following day, enter a SUSPEND action on the UCMS screen, effective the same date used on the basic decision notice. On CMUP, add the DOC C/D and N/R.

MAA: Upon release, reopen MAA medical on his own case and BED; redetermine medical, and close or reduce to OHP after timely notice.

OHP: Upon release, reopen OHP medical on his own case for the remainder of the current certification. If redetermination is due, redetermine immediately.


If good cause exists for late reporting, restore medical effective the date the client says they were released from incarceration.

If no good cause for reporting late, provide information for the OHP SRL and review for all other medical programs.

FSML – 64 MA-WG #4 January 1, 2012 SSP Medical Program Incarceration Policy & Coding Matrix Page - 3



& Reports Timely



Example 4: Individual on OHP with

family is incarcerated.

Because the system will not support a „suspend‟ action when there are others on the case, inmate‟s medical must be closed on the CM system. Enter a MEDI action on the UCMS screen for the first of the next month. On CMUP, end the inmate‟s

medical. Add a DOC C/D and DOC N/R.

Let family continue with OHP for remainder of certification period. If a redetermination is required while the inmate is incarcerated, redetermine for the family. If the rest of the family continues to be eligible, COMPUTE

the case forward for a new certification period.

Restore releasee to the same medical program he/she had prior to being incarcerated, even if the rest of the family is now on another medical program.

Example: If the releasee had been receiving OHP, restore to OHP even if the rest of the family has since moved to MAA. Redetermine eligibility for the entire filing group.

Example: If the releasee had been receiving OHP, restore to OHP. If the family is still on OHP and has not had a redetermination while the inmate was incarcerated, let the releasee continue through the remainder of the certification period with the family. If the family has been recertified for OHP while the inmate was incarcerated, BED the releasee and redetermine eligibility for the entire filing group.


If good cause exists, restore OHP medical, and follow the examples for timely reporting. Effective date would be the date the client says they were released.

If no good cause, do not restore medical.

Treat the date they reported the release as a new DOR, and determine eligibility for releasee and entire family. Provide information about the OHP Standard Reservation List (SRL).

MA-WG #4 FSML – 64 Page - 4 SSP Medical Program Incarceration Policy & Coding Matrix January 1, 2012


FSML – 59A MA-WG #5 November 1, 2010 List of SSP Medical Program Notices Page - 1

Worker Guide List of SSP Medical Program Notices

Worker Entered CM Closure and Denial Notices CR Eligibility/Review/Verification Not Completed DA OPC, OP6, OPP, OPU; Ineligible Noncitizen DB CHP; Ineligible Noncitizen DD OHP; 45-Day Limit DF OPU; Premium Past Due DG CHP; CHP Resources Exceed Limits DH OPU; Still on 6-Month Disqualification DM OHP; Eligible for Medicare DN OPU; OPU Receiving Major Medical DO OHP; Over Income DP OHP; Resident of Public Institution DR OHP; Does Not Meet Residence Requirements DT Deny Medicaid: Did not Verify Citizenship DU OHP; Unable to Locate DW Close Medicaid: Did not Verify Citizenship DX OHP; Resources Exceed Limits DY All Medical Denial (CM version of Notice of Medical Assistance Program

Eligibility Decision (DHS 462A)) System Generated Notices Based on Worker Action 1C TANF-related Medical Benefits Approved 1F Health Insurance Premium Reimbursement Approved (HIP) 1K OHP Program-Plus/CAWEM Medical Approved 1L Extended Medical Approved – Employment Requirements Met (sent when IE2,

AE1, or AE2 is added to case) 1N MAA/MAF Med Benefits Auto-Renewed 1S Medical Benefits Approved – BCP 1U BCP Medical Benefits Approved – Application Needed 1V Not Eligible Except for CAWEM – BCP 2A Suspended Case Restored 2K OHP Program- Standard/CAWEM Medical Approved 4S Extended Medical Approved – 4 Months 5M Extended Medical Approval – 12 Months 5S Extended Medical (4 months) and ERDC Approved 6M Extended Medical (12 months) and ERDC Approved 6T Cash Benefits Approved – Earnings Reported (includes TANF-related medical) 8N Benefits End, Retro Income Over TANF Limit (includes TANF-related medical) 9N Benefits End, Retrospective Income Over TANF Payment Standard (includes

TANF-related medical)

http://dhsforms.hr.state.or.us/Forms/Served/DE0462A.pdf�

MA-WG #5 FSML – 59A Page - 2 List of SSP Medical Program Notices November 1, 2010

Mid-Month CM Notices (mailed about the 15th) 01B Monthly Change Report Not Received (includes TANF-related medical) 02B Reduce TANF and Medical – Child Removed at Age 19 (Final) 4N Case Receiving Child Support Over Standard (includes TANF-related medical) 23B Health Insurance Sign-up – Advance (HIP) 24B Health Insurance Not Elected – Benefits End (HIP) 25B Health Insurance Premium Reimbursement Ending 32B OHP Closes, Pregnancy Ends 34B OHP Period Ends – Final Notice (AFS) 35B Notice to Apply for Medicare 36B Medicare Eligible, OHP ends (when OHP recipient turns 65) 38B OHP Child Removed at 19 – Advance Notice 40B OHP Period Ends – Advance Notice (SDSD) 41B OHP Period Ends – Benefits End (SDSD) 50B OHP Closes; Age 6 at 133% Level 51B EXT Ends – Advance Notice 52B OHP Closes; Age 1 at 185% (AENs) 53B BCCM Eligibility Ends – Advance Notice 54B BCCM Eligibility Ends – Final Notice 55B BCCM Redetermination – Advance Notice 56B BCCM Redetermination – Final Notice 58B OHP; Available Employer Sponsored Insurance – Final 59B OHP Child Removed at Age 19 – Final 60B EXT Ends - Only Eligible Child Turns 19 – Advance 61B EXT Ends - Only Eligible Child turns 19 – Final Notice 65B Reduce Medical, Child Removed at19 – Advance Notice 66B Reduce Medical; Child Removed at 19 – Final 67B Close Medical; No Eligible Child – Advance 68B Close Medical; No Eligible Child – Final 69B MAA/MAF – No Eligible Child (Final Notice) 71B Reduce TANF and Medical; Child Removed at Age 19 – Advance 72B Close TANF and Medical; Child Removed at Age 19 – Advance 73B TANF Pregnancy Ended, No Eligible Child – Advance 74B OHP Closes; Pregnancy Ends – Advance 75B Medical; 19-Year-Old Must Apply for Medical – Advance 76B Medical; 19-Year-Old Must Apply for Medical – Final 77B Eligibility/Review/Verification Not Completed 78B Extended Medical Ends – Report Requirements Late Month OHP CM Notices (mailed about the 20th) 01A SSN Needed; First Notice 1A Cash Benefits Approved (includes TANF-related medical) 04A Medical Review Overdue 05A UC Benefits Reported by Employment Division 33A OHP Period Ends – Advance Notice (AFS)

FSML – 59A MA-WG #5 November 1, 2010 List of SSP Medical Program Notices Page - 3

NOTR Notices CMBCM0P Request Citizenship/Immigration Information – BCCM CMCAREC Due Process Close At Recertification; OHP CMCBCM1 BCP Presumptive Period Ends – Need Form CMCBCM2 BCP Presumptive Period Ends – Need OHP Application CMCBCM3 BCP Presumptive Period Ends – Application Process Not Completed CMCBCM4 BCP Eligible – Client Only Wants Emergent Medical Services CMCBCM5 Medical Benefits Approved – BCP: Medical Application Needed CMCBCM6 Medical Benefits Approved – BCP CMCBCM7 BCCM Ends; No Longer Eligible CMCBCM8 BCCM Ends; Turning Age 65 CMCCTPR Major Medical Begins; Close CMCITPD Pend Medical; Proof of Citizenship CMCITST Medical; Citizen/Alien Status Met CMCOHOM OHP; Medicare Begins, Close CMCOHPC OHP CHP; Major Medical Begins; Close CMCOHST OHP; Ineligible Student CMC0FHP OHP; Close, No Cooperation with FHIAP CMC00CL Unable to Locate or Other State Benefits – Close CMC00CR Eligibility Review/Verification Not Done – Close CMD0ARR OHP; Deny – Premium Past Due CMC00CG Not Blind or Disabled; OSIP CMC00CK Does Not Meet Residency Requirement CMC00CL Unable to Locate – Close CMC00CM Resource Exceed Limits CMC0NSB Moved to Other State – Close CMC00CV Eligibility Verification CMC0OPP OHP Closes; Pregnancy Ends CMC00CP Working Over 100 Hours CMC00CR Eligibility Review/Verification Not Done – Close CMC00CT Unemployment Compensation Disqualification CMD00DA Client Withdrew Application CMD00DT Deny Medical; Did not Verify Citizenship CMC00DU Unable to Locate – Deny CMC00DW Close Medical; Did not Verify Citizenship CMC00IN Medical Suspended; Inmate CMC2FHP OHP; End Medical, FHIAP Begins CMDCMPD Children’s Medical Project Denial Notice CMDODEN OHP; OHP Medical Denial Notice CMDOHPM OPU, CHP; Deny – Private Health Insurance CMDOPUO OPU; Over Income CMDOSIP OSIPM Denial CMD0ARR OHP; Deny – Premium Past Due CMMAA1C MAA/MAF Medical Benefits Approved CMMED01 Not Eligible for Medically Related Travel Payment CMMEDTR Notice of Transfer CMMHCEN Medical; Medical Approved – Enrolled

MA-WG #5 FSML – 59A Page - 4 List of SSP Medical Program Notices November 1, 2010

CMNEWID Pend Medicaid; Newborn ID CMOHP01 Notice of Transfer – OHP CMOPHEN OHP; OHP Approved, Enroll in Plan CMR0FHP OHP; Reduce, No Coop w/FHIAP CMR2STD Reduce Benefits to Standard CM00694 ID Children Under 16 CM00695 Statement of Citizenship CM07294 Notice of Reported Income CM462A1 Deny or Close Medical Eligibility, Part 1 CM462A2 Deny or Close Medical Eligibility, Part 2 CM462C1 Deny or Close SSP Medical Eligibility, Part 1 CM462C2 Deny or Close SSP Medical Eligibility, Part 2 CM5503F Forwarded Application from 5503 GSCMPRV CMP Notice of Review GSC00CS Client Request to End Benefits GSC1F01 Close or Reduce Cont Benefits GSD1F01 Basic Decision Notice; Deny GSMAPRV Medical Benefits Approved GSMCHGN CMP; Notification of Address Change GSRETRO Retro Medical Approved GSR1F01 Reduce; Continuing Benefit Notice GSS1F01 Continuing Benefit Decision Notice – Suspend GSXTMED Extended Medical Approved GS0ESRD Apply for Medicare; ESRD GS00210 Notice of Pending Status GS0210A Notice of Information or Verification Needed GS00487 Notice of Incomplete Report GS0859B Self-Employed Monthly Report GSO211 OHP Health Plan Choice GSOH210 OHP Notice of Pending Status GSOSIPR OSIPM Referral

FSML - 51 MA-WG #6 10/01/08 Medical Start Dates Page - 1

Worker Guide Medical Start Dates

Initial month – For all but citizenship

documentation, allow 45 days from the DOR to provide verification. Once all verification has been provided, begin the medical on the date of request if otherwise eligible on that date. For citizenship documentation, allow as much time as necessary, as long as the client is showing a good-faith effort to obtain the documentation. Once provided, if otherwise eligible, begin medical on the DOR (see the “retro MAA/MAF” section for retroactive medical information).

TANF recipients who have not met the citizenship documentation requirements are not assumed eligible for MAA.

If documentation has been provided timely, but the client does not meet all eligibility requirements on the date of request, start medical the first day of eligibility following the DOR.

If there is already open medical in another state, Oregon medical may be opened IF the client cannot use their out of state medical care ID in Oregon. Be sure to narrate.

If there is medical with another DHS worker (including CW), make sure the other medical program eligibility on the other case is ended (even if it is in the middle of the month) before beginning the new eligibility.

If the other medical has already been closed and there has been no program change, narrate and begin the medical on the new case the first of the next month.

If the medical program was changed mid-month and the prior medical has already ended, send a Request for Medical Eligibility (AFS 148) to CMU to correct the prior medical end date.

MAA/MAF cont.

If converting from OHP-OPU to MAA/MAF, start the medical on the MAA/MAF DOR. If there was a premium billed for that month, remove the OHP premium using PADJ.

If there is an unpaid medical bill and the client

meets eligibility in each month back to the date of the medical service (up to 3 months proceeding the date of request), start medical for the eligible person on the medical service date and use the RM case descriptor. Start medical for all others in the benefit group on the date of request.

If the client has non-continuous retroactive medical (they do not meet eligibility in each month back to the date of service), start medical on the date of request & submit an AFS 148 to CMU for each month they meet retro eligibility.

If the income change was reported timely, the

EXT budget month is the last month of their MAA/MAF eligibility. Use the budget month as the last of the six months for the “3 of 6” month decision. Begin the EXT the first of the month following the last month of MAA/MAF eligibility.

If the change was not reported timely, use the month before the family lost MAA eligibility as the EXT budget month.

EXT cont.

Since we can now combine TANF and EXT on the same CM case, you may have a TANF/EXT combination case until you can close the TANF.

Note: Exclude a caretaker relative ‘s earned income that would make the family ineligible for MAA or MAF prior to meeting the three-of-six months EXT. Transitioning from another medical program –

Start medical the first of the month following the 10-day notice period (remember this will be a decrease in benefits).

OHP 7210R reservation list applicants –Start medical on the Date of Request, if eligible on that date.

Initial month – For all but citizenship

documentation, allow 45 days from the DOR to provide verification. Once verification has been provided, begin the medical on the date of request if otherwise eligible on that date. For citizenship documentation, allow as much time as necessary, as long as the client is showing a good faith effort to obtain the documentation. Once provided, if otherwise eligible, begin medical on the DOR.

Contact List

SSP-Policy, Medical Carol Berg 503 945-6072 Michelle Mack 503 947-5129 Joyce Clarkson 503 945-6106

MAA/MAF

RETRO MAA/MAF

EXT

OHP - OPU

OHP – OPC, OP6, CHP & OPP

FSML – 58C MA-WG #7 August 16, 2010 OHP Standard Reservation List Overview Page - 1

OHP Standard Reservation List Overview

Situation Overview of Steps Requesting an OHP Standard Reservation.

• Individuals may request a reservation for themselves or for someone else in their household, except that DHS/AAA staff may not request reservations for their clients.

• Reservation requesters may also ask that a third-party contact person be included on the reservation. If the requester is randomly selected, the contact person will be notified in addition to the requester.

• DMAP Outreach workers, health practitioners, community advocates and other members of the public may request reservation numbers.

Individuals may request a reservation by: • Going to the OHP Standard Reservation List website at

www.oregon.gov/DHS/open. • Calling the OHP Standard Reservation List Phone Bank at

1-800-699-9075 Monday through Friday from 7:00 AM to 6:00 PM. In Salem: 503-378-2666 TTY: 1-800-648-3458; 503-373-7800. The call will take 10 - 20 minutes.

• Submitting an OHP 3203 reservation list request form to a DHS office. The OHP 3203 request form may be left at any SPD/AAA/SSP office or mailed to the OHP Statewide Processing Center (branch 5503).

NOTE: Requesters from the 2008 Reservation List were mailed letters asking if they wanted to be on the 2009 List. You may continue to see the “opt-in” letters for some time. Treat them just like an OHP 3203 form.

Telling people about the OHP Standard Reservation List. • Reservation requesters may also ask that a third-party

contact person be included on the reservation. If the requester is randomly selected, the contact person will be notified in addition to the requester.

All SPD/AAA/SSP eligibility and reception staff should be able to explain the following:

• There is no planned closure date at this time. • Confirmation letters mailed every Wednesday. • The confirmation letter will ask if the requester wants a third

party contact. • Persons randomly selected from the list will be notified with a

letter. The OHP 3203 written reservation request form is dropped off at an SPD/AAA/SSP office.

All SPD/AAA/SSP offices except 5503: • Date stamp the OHP 3203. Scan and e-mail the request to

Reservation, Standard, or fax to 503-373-7866 or 503-378-4139 or shuttle the form to 5503.

NOTE: Please fax, shuttle, e-mail or mail the OHP 3203 or “opt-in” letter from the 2008 List daily. Do not send the paper form if you have already e-mailed or faxed it to 5503.

http://www.oregon.gov/DHS/open�

MA-WG #7 FSML – 58C Page - 2 OHP Standard Reservation List Overview August 16, 2010

Situation Overview of Steps OHP Standard Reservation List staff process the reservation list request.

5503 staff: • Add the request information to the Reservation List website. • Send a notice of incomplete request for written requests that do not

include name, address and/or DOB. • Send a notice to requesters who are under the age of 19 or age 65

and above. The notice refers them to the OHP application center. DMAP/SSP Central Office staff:

• Send a confirmation letter. Once a reservation request has been added, requesters will be sent an OHP 7210 application with the words “7210P” and “confirmation application” on the label. Persons on the list need to report changes, including but not limited to address changes, third party contact changes, alternate format, language changes or a new adult in the filing group.

Requesters: • Report changes by calling or e-mailing Reservation List staff

or notifying their local SPD/AAA/SSP office. All SPD/AAA/SSP offices:

• May receive the confirmation OHP 7210 applications and will date stamp and forward these applications to 5503.

• Whichever office receives the change is responsible for updating the OHP Standard Reservation List website. If the Web site is not available, e-mail Reservation, Standard.

OHP Standard Reservations are randomly selected. A DOR may be established on or after the random selection date up through 45 days after the 7210R mail date. DMAP:

• DMAP determines how many and when reservation numbers may be randomly selected based on available funding.

• DMAP sends congratulations “you have been selected” letter. OIS/SSP staff:

Sends application file to the OHP Mail Center.

OHP 7210R applications are mailed. • The OHP 7210R cover sheet explains that a DOR must be established within 45 days after the 7210R mail date. The applicant may not need to complete a new application. The cover sheet will also encourage use of the online OHP 7210W.

Applicant establishes DOR by calling, leaving a note or submitting completed OHP 7210R or other application. If the applicant already has an open DHS program case, their current application can be used.

All SPD/AAA/SSP offices: • Add DOR to Reservation List website for each adult in the

filing group on the Reservation. If necessary, adds new adult to the reservation.

FSML – 58C MA-WG #7 August 16, 2010 OHP Standard Reservation List Overview Page - 3

Situation Overview of Steps Eligibility workers process the OHP 7210R or other application.

5503: • If there is a companion case, forwards application to

companion case branch for processing. • If the applicant is age 60 years and above, 5503 forwards the

OHP 7210R to appropriate local SPD/AAA office. All other SSP offices and SPD/AAA offices:

• If age 50 and above, SPD/AAA office is responsible for eligibility determination.

• If there is a companion case, the companion case branch is responsible for the eligibility determination.

When sending applications to 5503 By Shuttle: By Mail: By Email: OHP Standard (Branch 5503) OHP Standard RESERVATION, Standard in GroupWise, or 2850 Broadway St NE PO Box 14520 [email protected] Salem, OR 97303-6500 Salem, OR 97309-5044 By Fax: 503-373-7493 (Please note: This fax number is different than the Reservation List requests fax numbers)

mailto:[email protected]�

MA-WG #7 FSML – 58C Page - 4 OHP Standard Reservation List Overview August 16, 2010


FSML – 65A MA-WG #8

May 1, 2012 Shelter-In-Kind, In-Kind and Earned Income Page - 1

Worker Guide for SSP Medical Programs

Shelter-In-Kind, In-Kind and Earned Income

“In-kind income” means income in a form other than money (such as food, clothing,

cars, furniture and payments made to a third party).

Note: In-kind income can be earned or unearned.

“Shelter-in-kind income” means an agency or person outside the financial group

(see OAR 461-110-0530) provides the shelter of the financial group, or makes a

payment to a third party for some or all of the shelter costs of the financial group.

Shelter-in-kind income does not include temporary shelter provided by a domestic

violence shelter, homeless shelter or residential alcohol and drug treatment facilities

or situations where no shelter is being provided, such as sleeping in a doorway, park

or bus station.

Example 1: A person who is not in the home is paying rent/mortgage/utilities

to the landlord, a mortgage company, and/or utility company

directly. This person is not legally obligated or paying in exchange

for any work or services. They are a friend or relative, but not a

charity organization or absent spouse or parent. This is shelter-in-

kind income under OAR 461-145-0470, and is not counted for

MAA, MAF, CHIP, OHP or HKC.

Example 2: Absent father is paying legally obligated child support. In addition

he is voluntarily paying rent/mortgage/utilities directly to the

company to help support the children. For MAA, MAF, CHIP,

OHP or HKC, this is counted as child support (unearned income).

Note: Third-party child support payments do not qualify for the child support disregard.

Example 3: Absent father is voluntarily paying rent/mortgage/utilities to the

landlord, mortgage and/or utility company. This is in lieu of child

support but not legally obligated or court ordered. For MAA,

MAF, CHIP, OHP or HKC, this is counted as child support

(unearned income).

Example 4: A friend or relative is living in the client’s home but is not in the

client’s filing group, and is paying rent/mortgage/utilities directly

to the company. The friend is not legally obligated to contribute

towards the rent/mortgage/utilities. Treat this as shelter-in-kind

income. For MAA, MAF, OHP, CHIP or HKC, this third-party

payment is not counted.

Example 5: Two roommates share an apartment; both are on the lease.

Roommate #1 pays her half of the rent to roommate #2, and

roommate #2 sends in the total rent payment. For the MAA, MAF,

CHIP, OHP or HKC programs, this is not considered income for



MA-WG #8 FSML – 65A

Page - 2 Shelter-In-Kind, In-Kind and Earned Income May 1, 2012

roommate #1; both are legally required to make their half of the

payment.

Example 6: A friend or relative is living in the client’s apartment (or a home

they rent) but is not in the client’s financial group, is not on the

lease, and is giving the client money towards the rent/utilities (but

none for food). The friend is not legally obligated to contribute

towards the rent/mortgage/utilities, but is renting a room from the

client or voluntarily contributing to the household expenses. Treat

the income as countable, unearned income for MAA, MAF, CHIP,

OHP or HKC.

Example 7: A client rents out rooms in his home (where he lives) and manages

the property 20 hours or more a week. This is considered income-

producing property. The income is counted as self-employment

income for MAF, CHIP, OHP and HKC, and earned income for

MAA.

Example 8: Client is helping on home owner’s or landlord’s property doing

maintenance. In exchange for his work, he is not paying part or all

of his rent. Client is not an employee of the home owner or

landlord. For MAA, MAF, CHIP, OHP or HKC, this is shelter-in-

kind, and not counted.

Example 9: Client is a pastor and the church is paying his rent/mortgage/

utilities in lieu of, or in addition to his salary. For MAA and MAF,

OHP, CHIP or HKC, count as earned income if the pastor is a

principal of the business or if the income is taxed*. If the

rent/mortgage/utilities are not taxed along with his pay, and he is

not a principal of the business, it is shelter-in-kind and not

counted.

Note: A principal of a business may, or may not be self-employed.

Example 10: Charity organization, county energy assistance or other

community resource is paying rent/mortgage/utilities to the

company directly or to the client. For MAA, MAF, CHIP, OHP or

HKC, this is shelter-in-kind and not counted.

Example 11: Client is the principal of a business and is paying his personal

rent/mortgage/utilities to the company directly from the business

bank account. For MAA, MAF, CHIP, OHP or HKC, the payments

for his personal rent/mortgage/utilities are counted as his earned

income.

Note: A principal of a business may, or may not be self-employed.

Example 12: Client is working for a rental company as an apartment manager,

cleaning or doing other maintenance and receives hourly or salary

FSML – 65A MA-WG #8

May 1, 2012 Shelter-In-Kind, In-Kind and Earned Income Page - 3

pay. Client is living in the rental company’s house or apartment. In

exchange for her work, she is not paying for part or all of her rent.

For MAA, MAF, OHP, CHIP or HKC, the rental amount is

counted as earned income if it is on the pay stub as part of her

total gross income and taxed. If it is not added to her gross pay

and taxed, it is not considered part of her earned income. This is

shelter-in-kind income and would not be counted.

Example 13: Client is receiving housing assistance (section 8, housing

authority) which is paid directly to the rental company. For MAA,

MAF, CHIP, OHP or HKC, this is not counted.

Example 14: Client is receiving utility assistance that is paid directly to the

company or the client receives a monthly utility assistance check.

For MAA, MAF, CHIP, OHP or HKC, this is not counted.

Note: Some Self-Sufficiency medical programs do not have income limits, such as EXT,

CEC and CEM, and the situations above do not apply to these programs. BCCTP

(formerly BCCM) has an income limit, but the eligibility is presumptively

determined by a qualified provider, and not by DHS/OHA staff.

For medical, when the income is taxed, it becomes earned income, and is considered to be given in the

form of money even though it is then deducted off the pay for the housing or apartment cost. Thus, it is

not ‘in a form other than money, so is not shelter-in-kind income. Instead, the employer has increased

their employee’s earned income for the amount of the housing or apartment, taxed it, and then deducted

the cost of their housing or apartment from the pay. If it is not taxed, it is shelter-in-kind income.

MA-WG #8 FSML – 65A

Page - 4 Shelter-In-Kind, In-Kind and Earned Income May 1, 2012


FSML – 61 WG-MA#9 April 1, 2011 OHP-OPU Referral and Notices for OSIPM Presumptive Page - 1

Worker Guide OHP-OPU Notice and OSIPM Presumptive Referral Matrix

When an adult applicant is not eligible for OHP-OPU but indicates a disability, determine if he/she meets the referral criteria outlined at: http://www.dhs.state.or.us/spd/tools/program/osip/wg4.htm. If necessary, make an OSIPM presumptive referral to SPD. The chart below explains the notice requirements for OHP-OPU clients.

http://www.dhs.state.or.us/spd/tools/program/osip/wg4.htm�

WG-MA #9 FSML - 61 Page - 2 OHP-OPU Referral and Notices for OSIPM Presumptive April 1, 2011

Scenario OSIPM- Presumptive

Referral Criteria?

New OHP- OPU

Applicant?

Action/Required Notice(s)

Adult OHP-OPU applicant is not transitioning into OHP-OPU from another medical program and was not selected from the Reservation List. No disability is listed on the application.

No: there is no indication he is disabled.

Yes Deny the OHP-OPU request by sending the DHS 462A notice. No other notice is required.

Adult OHP-OPU applicant is not transitioning into OHP-OPU from another medical program and was not selected from the Reservation List. Applicant indicates he is waiting for a liver transplant, unable to work and has no income.

Yes Yes Deny the OHP-OPU request by sending the DHS 462C notice. No other notice is required.

Following your local referral process, refer to SPD.

Adult OHP-OPU applicant has been selected from the Reservation List. Applicant indicates he is disabled; he has a broken arm. OHP-OPU applicant does not meet eligibility criteria for OHP-OPU.

No: his broken arm does not meet OSIPM-Presumptive referral criteria.

No Deny the OHP-OPU request by sending a DHS 456 or other notice (DR, DO, etc.) giving specific reasons for the ineligibility, (over income, over resource, etc.).

Also, send the DHS 462A notice.

Adult applicant has been selected from the Reservation List, but does not meet eligibility criteria for OHP-OPU. He indicates a disability. Has chronic, permanent health issues that will prevent him from working.

Yes: indicates he is disabled and meets the referral process criteria.

No Deny the OHP-OPU request by sending a DHS 456 or other notice (DR, DO, etc.) giving specific reasons for the ineligibility, (over income, over resource, etc.).

Also, send the DHS 462C notice. Following your local referral process, refer to SPD.

http://dhsforms.hr.state.or.us/Forms/Served/de0462a.pdf�

http://dhsforms.hr.state.or.us/Forms/Served/de0462c.pdf�


http://dhsforms.hr.state.or.us/Forms/Served/de0456.pdf�

http://dhsforms.hr.state.or.us/Forms/Served/de0462c.pdf�

FSML – 61 WG-MA#9 April 1, 2011 OHP-OPU Referral and Notices for OSIPM Presumptive Page - 3

Scenario OSIPM- Presumptive

Referral Criteria?

New OHP- OPU

Applicant?

Action/Required Notice(s)

Adult OHP-OPU applicant has been receiving EXT for a year and is reapplying. He now meets eligibility for OHP-OPU. He does not indicate a disability.

No: there is no indication he is disabled

No. He is transitioning from another program

Reduce medical by sending a DHS 456 or other notice (CMCAREC, CMCCTPR, etc) giving specific reasons for the ineligibility (over income, over resource, etc.). Also send the DHS 462R or CMR2STD

Adult OHP-OPU applicant has been receiving MAA but is no longer eligible. Per review, does not meet the eligibility criteria for OHP-OPU or any other programs. Does not indicate a disability.

No: there is no indication he is disabled.

No. This client could have transitioned to OHP-OPU but was not eligible.

Close medical by sending a DHS 456 or other notice (CMCAREC, CMCCTPR, etc) giving specific reasons for the ineligibility (over income, over resource, etc.).

Also, send the DHS 462A notice.

Adult applicant has been receiving EXT. Does not meet eligibility criteria for OHP-OPU. He has chronic, permanent health issues that will prevent her from working for over 12 months.

Yes: indicates she is disabled and meets the referral process criteria.

No. This client could have transitioned to OHP-OPU but was not eligible.

BED the case to keep the client on EXT.

Following your local referral process, refer. If SPD denies the case, send a DHS 456 or other notice listing the specific reasons for ineligibility. SPD will have already sent an SDS 462A, so no DHS 462A is needed.





http://dhsforms.hr.state.or.us/Forms/Served/SE0462A.pdf�


WG-MA #9 FSML - 61 Page - 4 OHP-OPU Referral and Notices for OSIPM Presumptive April 1, 2011


FSML – 60E MA-WG #10 February 15, 2011 BED Quick Reference Guide Page - 1

Worker Guide BED Quick Reference Guide

February 2011

What programs are affected by the “due process” requirements and the BED need/resource (n/r)? All CAF SSP medical programs except REFM and HKC subsidy cases (KCE coding) require due process related “BED” coding.

Due process means DHS is responsible for sending decision notices and following legal requirements when pending, approving, denying or ending benefits. OSIPM cases also follow due process requirements, but SPD has not added the BED coding to SPD programs. What is the BED n/r and what does it do? The Bypass End Date (BED) need/resource item stops the CM system from automatically closing SSP medical and/or TANF benefits. It only works if there is an end date to bypass. The BED n/r also stops automatically generated notices from going out, except for the 77B “Eligibility Review/Verification Not Completed – Close” notice and notices sent to 19-year-olds who will lose medical benefits. The 77B is also not sent when there is a KCA need/resource on the case.

How are TANF benefits affected? TANF cases will automatically close based on the RVW date. Clients will automatically be sent the 77B close notice if no BED is added to the TANF case.

When do you add a BED n/r to a case? When the client has established a DOR for TANF or CAF SSP medical (except REFM and KCE) and • You need to pend for an eligibility decision; • The client is no longer eligible for any

medical benefits and you need more time to send a 10-day close notice and you do not want the CM system to auto close the case;

• The client is no longer eligible for the same level of benefits and you need to keep the case open so you can send a 10-day notice of reduction.

How does a client establish a DOR? • Verbally, as for example, by phone call or

at an office visit. • By written note. • By turning in an application or

reapplication.

How do I know what the BED n/r end date should be? The 77B close notice must be sent after the 45th day. The CM system automatically sends the 77B 10-day notice on the 15th of each month. The 45th day must end on or before the 15th of the month to use that month as the BED end date.

• If you need to pend the redetermination, allow for the pend period plus the 10-day notice time period when determining the BED end date. For example, if the 45th day is April 14, the BED need/resource end date is 04/XX. If the 45th day is April 16th, the BED need/resource end date is 05/XX.

• If you already know the client is ineligible, BED the case for next month so you can keep benefits open to send the 10-day notice. Send the 10-day notice explaining why the client is no longer eligible for benefits effective the end of next month. Send the DHS 462A too. The next month, remove the BED coding before the 15th of the month and end benefits.

• If you already know the client is OHP-OPU eligible but you need time to send the 10-day notice of reduction, the BED end date will be next month. Send a 10-day reduction notice. The next month remove the BED coding before the 15th of the month and compute the client to OHP-OPU effective the first of the following month.

• If the pended items have been returned and the client is no longer eligible, send the 10-day close with DHS 462A. If a new applicant, the client is disabled and a referral for OSIPM presumptive is required, send the DHS 462C and refer to SPD.



http://dhsforms.hr.state.or.us/Forms/Served/DE0462C.pdf�

MA-WG #10 FSML – 60E Page - 2 BED Quick Reference Guide February 15, 2011

What about the next OHP Certification period? The months received while BEDded pending eligibility are part of the next OPU, OPC, OP6 or CHP certification period. How do I restore an OHP case that has already closed because it is after CM compute deadline but the client establishes a DOR before the end of the month?

On the UCMS screen, enter a “Restore” action. The effective date is the first of the month after closure.

Go to CMUP. Enter the BED n/r item. Restore the appropriate client(s)= medical start dates. Using the same dates as before the case closed, add the OPU, CHP, OPC, OP6 or OPP DUE need/resource items.

Once the case is restored with the BED n/r, CM system will keep the case open until the BED n/r date expires. No approval notice will be mailed. How do I track which cases have a BED? The weekly WCM4369R-A “List of Cases with BED N/R” lists the cases with a BED code and the BED end date.

Special procedures for 19-year olds: If the client is OPC or CHP and turning age 19, do not leave the 19-year-old on his/her parent’s case:

Enter a Compute and the 19-year-old’s OPC/CHP on the parent’s case effective the day prior.

The same day, open a new CM case and begin medical effective that day (so there is no gap in medical coverage).

Because of an MMIS issue, open using the “MAA workaround.” Open as MAA medical and narrate that because of a technical system issue, the 19-year-old’s medical was opened as MAA instead of OPC or CHP..

What does the BED close notice say? The 77B/CR notice text includes the following:

“The Department will end your cash and/or medical benefits on XXXXXXX. You did not complete the eligibility review. We do not have enough information to know if you qualify for DHS program benefits.

You have the right to reapply at any time.”

Due process related rules include all of the hearing-related rules. Due process related rules also include:

Date of Request OAR 461-115-0030

When An Application Must Be Filed OAR 461-115-0050

Application Processing Time Frames; Not Pre-TANF or SNAP OAR 461-115-0190

Acting on Reported Changes; EXT, MAA, MAF, OHP, OSIPM, QMB, SAC OAR 461-170-0130

Effective Dates; Redeterminations of CEC, CEM, EXT, MAA, MAF, OHP, OSIPM, QMB, SAC OAR 461-180-0085

Medical Policy Resources

SSP-Policy, Medical in Group Wise

Joyce Clarkson 503-945-6106 Michelle Mack 503-947-5129 Carol Berg 503-945-6072 Vonda Daniels 503-945-6088 Audray Hunter 503-947-5519 Jewel Kallstrom 503-947-2316

http://apps.state.or.us/caf/arm/A/461-115-0030.htm�



http://apps.state.or.us/caf/arm/B/461-170-0130.htm�

http://apps.state.or.us/caf/arm/B/461-180-0085.htm�

mailto:[email protected]�

FSML - 69

April 1, 2013 DMAP Worker Guides DMAP WG - 1

FOR DMAP (DIVISION OF MEDICAL ASSISTANCE PROGRAMS) WORKER

GUIDES, PLEASE VISIT THE DMAP WORKER GUIDES WEBSITE AT:



FSML - 69

DMAP WG - 2 DMAP Worker Guides April 1, 0213

I:\CAF SSP POLICY\Family Services Manual\Draft\PDFs\dmap-wg.doc 3/12/2013


FSML - 47 10/01/07 Adult Programs AP - 1

I:\CAF\WPFILES\FAP\DRAFT\FSM\08ap.doc 9/27/2007

FOR ADULT PROGRAMS INFORMATION, PLEASE VISIT THE SPD WORKER GUIDES WEBSITE AT: http://www.dhs.state.or.us/spd/tools/additional/workergd/index.htm

table of contents - dhs.state.or.us · fsml – 70c august 23, 2013 medical assistance programs toc...

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