461-135-0010    Effective 02/18/21 - Technical Amendment
Assumed Eligibility for Medical Programs

  1. This rule sets out when a client is assumed eligible for certain medical programs because the client receives or is deemed to receive benefits of another program.

  2. A pregnant woman who is eligible for and receiving benefits the day the pregnancy ends is assumed eligible for the OSIPM program until the last day of the calendar month in which the 60th day after the last day of the pregnancy falls.

  3. A pregnant woman who was eligible for and receiving medical assistance under the OSIPM program or HSD medical programs (see OAR 461-001-0000) and becomes ineligible while pregnant is assumed eligible for Medicaid and can continue to receive OSIPM or HSD medical programs benefits until the last day of the calendar month in which the 60th day after the last day of the pregnancy falls.

  4. A child (see OAR 461-001-0000) born to a mother eligible for and receiving OSIPM benefits is assumed eligible for medical benefits under this section until the end of the month the child turns one year of age.

  5. The individuals described in subsection (a) and (b) of this section are assumed eligible for OSIPM (except OSIPM-EPD) unless subsection (c) or (d) of this section applies:

    1. A recipient of SSI benefits who meets all non-financial requirements for the OSIPM program except citizen and non-citizen status.  SSI recipients are presumed to meet all citizen and non-citizen status requirements for the OSIP program.

    2. An individual who meets all non-financial requirements for the OSIPM program except citizen and non-citizen status and is deemed eligible for SSI under Sections 1619(a) or (b) of the Social Security Act (42 U.S.C. 1382h(a) or (b)), which cover individuals with disabilities whose impairments have not changed but who have become gainfully employed and have continuing need for OSIPM. Individuals deemed eligible for SSI under Sections 1619(a) or (b) of the Social Security Act are assumed to meet all citizen and non-citizen status requirements for the OSIPM program.

    3. An individual described in subsection (a) or (b) of this section who is in a nonstandard living arrangement (see OAR 461-001-0000) is not eligible for long-term care (see OAR 461-001-0000) services if the individual would otherwise be ineligible for OSIPM due to a disqualifying transfer of assets (OAR 461-140-0210 to 461-140-0300 regulate the effect of a transfer of assets on a client).

    4. An individual described in subsection (a) or (b) of the section who is in a nonstandard living arrangement is not assumed eligible for long-term care services if countable (see OAR 461-001-0000) resources exceed the limit after performing the calculation under OAR 461-160-0580.

  6. For the purposes of this section the definition of a "child" means an unmarried individual under age 19 and includes natural, step, and adoptive children. A child found eligible for OSIPM is assumed eligible until the end of the twelfth month following the determination of the child's OSIPM eligibility or redetermination of eligibility unless the child:

    1. No longer meets the definition of a child given in this section;

    2. Moves out of state;

    3. Voluntarily ends benefits; or

    4. Is eligible for any other Medicaid program that provides OHP Plus benefits.

  7. A client who receives both benefits under Part A of Medicare and SSI benefits is assumed eligible for the QMB-BAS program unless the individual does not meet the requirements of OAR 461-120-0345 or the residency requirements (see OAR 461-120-0010).

Statutory/Other Authority: ORS 409.050, 411.060, 411.070, 411.404, 413.085, 414.685
Statutes/Other Implemented: ORS 409.010, 411.060, 411.070, 411.404

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