461-135-0010 Effective 07/01/12
Assumed Eligibility for Medical Programs
- 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.
- A pregnant woman who is eligible for and receiving benefits the day the pregnancy ends is assumed eligible for the EXT, MAA, MAF, OHP (except OHP-CHP), OSIPM, or SAC program until the last day of the calendar month in which the 60th day after the last day of the pregnancy falls.
- A pregnant woman who was eligible for and receiving medical assistance under any Medicaid program and becomes ineligible while pregnant is assumed eligible for Medicaid until the last day of the calendar month in which the 60th day after the last day of the pregnancy falls.
- A child (see OAR 461-001-0000) born to a mother eligible for and receiving EXT, MAA, MAF, OHP, OSIPM, or SAC benefits is assumed eligible for medical benefits under this section until the end of the month the child turns one year of age.
- The following children are assumed eligible for SAC:
- 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 is in effect between a public agency of the state of Oregon and the adoptive parents that indicates the child is eligible for Medicaid.
- The individuals described in subsection (a) and (b) of this section are assumed eligible for OSIPM (except OSIPM-EPD) unless subsection (c) or (d) of this section applies:
- A recipient of SSI benefits.
- An individual deemed eligible for SSI under Sections 1619(a) or (b) of the Social Security Act (42 U.S.C. 1382h(a) or (b)), which cover individuals with disabilities whose impairments have not changed but who have become gainfully employed and have continuing need for OSIPM.
- 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).
- 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 resources exceed the limit after performing the calculation under OAR 461-160-0580.
- 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 the REFM program 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
- 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.
Stat. Auth.: ORS 409.050, 411.060, 411.070, 411.404, 412.049
Stats. Implemented: ORS 409.010, 411.060, 411.070, 411.404, 412.049, 414.025