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

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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.

1. Application process

   When a request is made for SAC medical assistance, use the Application for Children in Substitute Care (DHS 1462) or the Medical Assistance Application for Children Receiving Adoptive Care (DHS 1462A).

   DHS 1462 applications are completed by facilities on the behalf of children in substitute care. The DHS 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.

   DHS 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 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 DHS 1462, DHS 1462A, MSC 415F, OHP 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	LESLEE.V.STAR@dhs.oregon.gov
     Margaret L. Roberts	MARGARET.L.ROBERTS@dhs.oregon.gov

   
   

2. Specific program requirements

   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.

   Children subject to an adoption assistance agreement described above are assumed eligible for the SAC program.

   Assumed Eligibility for Medical Programs: 461-135-0010
   Specific Requirements; SAC: 461-135-0150

   
   

3. Eligibility Groups

   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 togther?)

   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: 461-110-0630

   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

   
   

4. Financial Eligibility

   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.

   Availability of Resources: 461-140-0020
   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.

   When An Application Must Be Filed: 461-115-0050
   Verification; General: 461-115-0610
   Required Verification; BCCM, EXT, HKC, MAA, MAF, OHP, SAC: 461-115-0705

   
   

6. Effective dates; initial month medical benefits

   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 within 45 days following the date of request that all eligibility requirements are met.

   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