Current through Register Vol. 63, No. 9, September 1, 2024
(1) Except as
provided in this rule, the Authority shall send:
(a) A basic decision notice whenever an
application for HSD Medical Program benefits is approved or denied;
(b) A timely continuing benefit decision
notice whenever HSD Medical Program benefits are reduced or
closed.
(2) Exceptions to
the requirement to provide timely continuing decision notice when HSD Medical
Program benefits are reduced or closed:
(a)
When a beneficiary becomes a resident of a public institution or correctional
facility, the Agency shall send a basic decision notice to close, reduce, or
suspend benefits;
(b) When a
beneficiary has been placed in skilled nursing care, intermediate care, or
long-term hospitalization, the Agency shall send a basic decision notice to
close, suspend, or reduce benefits;
(c) When returned postal mail is received
without a forwarding address and the beneficiary's whereabouts are unknown, the
Authority shall send a basic decision notice to end benefits.
(d) When a beneficiary ceases to be an Oregon
Resident and the Agency is informed that they're eligible for medical benefits
in another state, the Agency shall send a basic decision notice to end
benefits;
(e) When a beneficiary,
another adult member of the EDG, or the authorized representative requests
benefits be closed, and the request includes a written or recorded verbal
signature, the Agency shall send a basic decision notice to end
benefits;
(f) When an individual
who is not a recipient of any Medicaid/CHIP benefits makes a request to
withdraw an application for benefits, the Agency shall send a basic decision
notice.
(3) No decision
notice is required in the following situations:
(a) The only individual in the EDG
dies;
(b) A hearing was requested
after a notice was received and either the hearing request is dismissed, or a
final order is issued.
(4) Decision notices shall be written in
plain language and be accessible to individuals who are limited English
proficient and individuals with disabilities.
(5) All decision notices shall include:
(a) A statement of the action
taken;
(b) A clear statement
listing the specific reasons why the decision was made and the effective date
of the decision;
(c) Rules
supporting the action;
(d)
Information about the individual's right to request a hearing and the method
and deadline to request a hearing;
(e) A statement indicating under what
circumstances a default order may be taken;
(f) Information about the right to counsel at
a hearing and the availability of free legal services.
(6) A decision notice approving HSD Medical
Program benefits, including approvals for retroactive medical, shall include:
(a) The level of benefits and services
approved;
(b) If applicable,
information relating to premiums, enrollment fees, and cost sharing;
and
(c) The changes that must be
reported and the process for reporting changes.
(7) A decision notice reducing, denying, or
closing HSD Medical Program benefits shall include information about a
beneficiary's right to continue receiving benefits.
(8) When electronic-only is the preferred
communication method, and the Agency is unable to successfully deliver an
electronic notification, the Agency shall send the notice by postal mail within
three business days. The date on the notice shall be the date the notice is
sent by postal mail.
(9) The
Authority may amend:
(a) A decision notice
with another decision notice; or
(b) A contested case notice.
(10) Except as the notice is
amended, or when a delay results from the client's request for a hearing, a
notice to reduce or close benefits becomes void if the reduction or closure is
not made effective on the date stated on the notice.
(11) The Authority shall provide individuals
with a choice to receive decision notices and information referenced in this
rule in an electronic format or by postal mail. If an individual chooses to
receive notices and information electronically and has established an online
account with the Applicant Portal of Oregon Eligibility (ONE), the Authority
shall:
(a) Send confirmation of this decision
by postal mail;
(b) Post notices to
the individual's electronic account within one business day of the date on the
notice;
(c) Send an email or SMS
text message alerting the individual that a notice has been posted to their
electronic account;
(d) At the
request of the individual, send by postal mail any notice or information
delivered electronically;
(e)
Inform the individual of the right to stop receiving electronic notices and
information and begin receiving these through postal mail; and
(f) If any electronic communication
referenced above is undeliverable, send the notice by postal mail within three
business days of the failed communication.
Statutory/Other Authority: ORS
411.402, ORS
411.404,
413.042,
414.534, 42 CFR: 431.213,
435.110, 435.112, 435.115, 435.116, 435.118, 435.940, 435.1200, 458.350, 435.3,
435.4, 435.407, 435.952, 435.1008, 457.320, 435.406, 457.380, 435.117, 435.170,
435.190, 435.916, 435.917, 435.926, 435.1205, 447.56, 457.340, 457.350,
457.360, 457.805, 433.145, 433.147, 433.148, 433.146, 435.610, 435.403, 457.80,
435.119, 435.222, 435.602, 435.608, 435.956 & 433.138
Statutes/Other Implemented: ORS
411.404,
414.534, ORS
411.400,
411.402,
411.406,
411.439,
411.443,
413.032,
413.038,
414.025,
414.231,
414.536,
414.706,
411.060,
411.095 &
414.440
