Release 65A:  Effective May 1, 2012

Medical Assistance Programs -
B.  Assumed Eligibility


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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:

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.

Assumed Eligibility for Medical Programs: 461-135-0010

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