Current through Register Vol. 63, No. 9, September 1, 2024
With the exception of OHP Bridge - Basic Medicaid, this rule
sets out when an individual is presumptively eligible for MAGI Medicaid/CHIP,
BCCTP, and FFCYM (OAR
410-200-0407) based on the
determination of a qualified hospital. In addition, presumptive eligibility for
OHP Bridge Basic Health Program cannot be established based on the
determination of a qualified hospital.
(1) A qualified hospital shall, with the
consent of the individual or someone acting on the individual's behalf,
determine Hospital Presumptive Eligibility (HPE) for MAGI Medicaid/CHIP, BCCTP,
or FFCYM.
(2) The qualified
hospital shall determine Hospital Presumptive Eligibility based on the
following information attested by the individual:
(a) Family size;
(b) Household income;
(c) Receipt of other health
coverage;
(d) Residency
(e) US citizenship, US national, or
non-citizen status.
(3)
To be eligible via Hospital Presumptive Eligibility, an individual must be a US
citizen, US National, or meet the citizenship and non-citizen status
requirements found in OAR
410-200-0215 and one of the
following:
(a) A child under the age of 19
with income at or below 300 percent of the federal poverty level;
(b) A parent or caretaker relative of a
dependent child with income at or below the MAGI Parent or Caretaker Relative
income standard for the appropriate family size in OAR
410-200-0315;
(c) A pregnant individual with income at or
below 185 percent of the federal poverty level;
(d) A non-pregnant adult between the ages of
19 through 64 with income at or below 133 percent of the federal poverty level;
or
(e) An individual under the age
of 65 who has been screened by a licensed healthcare provider and determined to
need treatment for breast or cervical cancer, or who has been determined
eligible for the Breast and Cervical Cancer Treatment Program (OAR
410-200-0400);
(f) An individual under the age of 26 who was
in Oregon foster care on their 18th birthday.
(4) To be eligible via Hospital Presumptive
Eligibility, an individual may not:
(a) Be
receiving Supplemental Security Income benefits;
(b) Be a Medicaid/CHIP beneficiary;
or
(c) Have received a Hospital
Presumptive Eligibility approval start date within the year (365 days) prior to
a new Hospital Presumptive Eligibility period start date.
(5) In addition to the requirements outlined
in sections (3) and (4) above, the following requirements also apply:
(a) To receive MAGI Adult benefits via
Hospital Presumptive Eligibility, an individual may not be entitled to or
enrolled in Medicare benefits under part A or B of Title XVIII of the
Act;
(b) To receive MAGI CHIP
benefits via Hospital Presumptive Eligibility, an individual may not be covered
by any minimum essential coverage that is accessible (OAR
410-200-0410(2)(c));
(c) To receive BCCTP benefits via Hospital
Presumptive Eligibility, an individual may not be covered by any minimum
essential coverage.
(6)
The Hospital Presumptive Eligibility period begins on the earlier of:
(a) The date the qualified hospital
determines the individual is eligible; or
(b) The date that the individual received a
covered medical service from the qualified hospital, if the hospital determines
the individual is eligible and submits the decision to the Authority within
five (5) calendar days following the date of service.
(7) The Hospital Presumptive Eligibility
period ends:
(a) For individuals on whose
behalf a Medicaid/CHIP application has been filed by the last day of the month
following the month in which the hospital presumptive eligibility period
begins, the day on which the state makes an eligibility determination for MAGI
Medicaid/CHIP and sends basic decision notice; or
(b) If subsection (7)(a) is not completed,
the last day of the month following the month in which the hospital presumptive
eligibility period begins.
(8) A Hospital Presumptive Eligibility
approval is not a full eligibility determination and does not entitle
beneficiaries to the following:
(a) A child is
not entitled to continuous eligibility (OAR
410-200-0135) based solely on
the receipt of benefits during a period of Hospital Presumptive
Eligibility;
(b) A baby born to an
individual receiving benefits during a period of hospital presumptive
eligibility is not assumed eligible (OAR
410-200-0135) based solely the
Hospital Presumptive Eligibility determination of the parent;
(c) An individual is not entitled to EXT (OAR
410-200-0440) based solely on
the receipt of MAGI PCR during a period of Hospital Presumptive
Eligibility;
(d) An individual
whose Hospital Presumptive Eligibility period is terminated due to
incarceration is not entitled to automatic restoration of benefits upon release
(OAR 410-200-0140);
(e) Individuals are not entitled to hearing
rights (OAR 410-200-0145) for benefits
received during a period of Hospital Presumptive Eligibility.
Statutory/Other Authority: ORS
411.402,
411.404,
413.042 &
414.534
Statutes/Other Implemented: ORS
411.400,
411.402,
411.404,
411.406,
411.439,
411.443,
413.032,
413.038,
414.025,
414.231, 414.447,
414.534,
414.536,
414.706 &
414.241
