461-180-0090    Effective 07/06/21 - Technical Amendment
Effective Dates; Initial Month Medical Benefits

The effective date for starting medical benefits for an eligible client is as follows:

  1. In the OSIPM and QMB-DW programs:

    1. Except as provided for in subsections (b) to (h) of this section:

      1. If the client meets all eligibility requirements on the date of request (see OAR 461-115-0030), it is the first day of the month that includes the date of request. An OSIPM program client who is assumed eligible under OAR 461-135-0010(5) meets "all eligibility requirements" for the purposes of this section as follows:

        1. Effective the first day of the month of the initial SSI payment if the client is age 21 or older.

        2. Effective the first day of the month prior to the month of the initial SSI payment if the client is under the age of 21.

      2. If the client does not meet all eligibility requirements on the date of request, but meets all requirements after the date of request, within the application processing time frames of OAR 461-115-0190, it is the first day of the month that includes the date that all eligibility requirements are met.

    2. If the client does not complete the application within the time period described in OAR 461-115-0190 (including the authorized extension), the determination of an effective date requires a new date of request.

    3. Except as provided for in subsections (d) and (e) of this section, for a new applicant who is a resident of a public institution (see OAR 461-135-0950) on any day of the month during the month that the applicant is determined to meet all eligibility requirements, the effective date is determined in accordance with subsections (a) and (b) of this section, except that coverage is not in effect for any day during the month that the applicant is a resident of a public institution  other than the date of incarceration and the date of release.

    4. The effective date for a resident of a public institution meeting the requirements of OAR 461-135-0950 regarding applications received by individuals with a serious mental illness is determined in accordance with OAR 461-135-0950.

    5. The effective date for an individual meeting the eligibility requirements of OAR 461-135-0950 regarding residents of a state psychiatric institution is the date that all eligibility requirements are met, including other chapter 461 eligibility requirements, if those requirements are met within the application processing time frames of OAR 461-115-0190. Otherwise the requirements of subsection (b) of this section apply.

    6. The effective date for a resident of a public institution  with suspended benefits that will be reinstated is determined in accordance with OAR 461-135-0950. If benefits will not be reinstated the resident of a public institution is considered a new applicant and the effective date is determined in accordance with subsection (c) of this section.

    7. The effective date for a new applicant who is receiving Medicaid in another state on the date of request, but meets the requirements of OAR 461-165-0030 regarding receipt of medical benefits in another state is:

      1. The date of request if all eligibility requirements are met on the date of request or after the date of request, but during the month that includes the date of request.

      2. If all eligibility requirements are not met during the month that includes the date of request the effective date is determined in accordance with paragraph (1)(a)(B) and subsection (b) of this section.

    8. The effective date for an applicant receiving Medicaid in another state prior to the date of request, but during the month that includes the date of request, is the day following the day that Medicaid benefits end in the other state if all eligibility requirements are met during the month that includes the date of request. If all requirements are not met in the month that includes the date of request the effective date is determined in accordance with paragraph (1)(a)(B) and subsection (b) of this section.

  2. In the OSIPM program, if an individual has been released from a correctional institution and is determined eligible for OSIPM, the effective date of beginning the individual’s medical assistance is the date the individual is released from the correctional facility or the date the individual begins the period of hospitalization outside of the correctional facility.

  3. In the QMB-BAS program, it is the first of the month after the benefit group (see OAR 461-110-0750) has been determined to meet all QMB-BAS program eligibility criteria and the Department receives the required verification.

  4. In the QMB-SMB and QMB-SMF programs, it is--

    1. The first of the month in which the benefit group meets all program eligibility criteria and the Department receives the required verification; or

    2. The first of the month in which the Low Income Subsidy (LIS) information is received by the Social Security Administration (SSA), if the SMB or SMF program application was generated by the electronic transmission of LIS data from the SSA and the benefit group meets all program eligibility criteria.

  5. In the REFM program:

    1. Except as provided in subsection (b) of this section:

      1. If the individual meets all eligibility requirements on the date of request (see OAR 461-115-0030), it is the date of request.

      2. If the individual 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.

    2. If the individual does not complete the application within the time period described in OAR 461-115-0190 (including the authorized extension), the determination of an effective date requires a new date of request.

  6. Retroactive eligibility is authorized under certain circumstances in some medical programs (see paragraph (1)(a)(A) of this rule, OAR 461-135-0875, and 461-180-0140).

Stat. Auth.: ORS 409.010, 409.050, 411.060, 411.070, 411.404, 411.704, 411.706, 413.085, 414.685, 414.839
Stats. Implemented: ORS 409.010, 409.050, 411.060, 411.070, 411.404, 411.439, 411.447, 411.704, 411.706, 413.085, 414.685, 414.839

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