Oregon Administrative Rules
Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS
Division 200 - ELIGIBILITY FOR HEALTH SYSTEMS DIVISION MEDICAL PROGRAMS
Section 410-200-0135 - Assumed, Continuous, and Protected Eligibility

Universal Citation: OR Admin Rules 410-200-0135

Current through Register Vol. 63, No. 9, September 1, 2024

(1) Assumed Eligibility:

(a) A child born to an individual who is eligible for and receiving Medicaid/Children's Health Insurance Program (CHIP) benefits at the time of the birth is an assumed eligible newborn (AEN);

(b) An AEN is eligible for MAGI Child benefits (OAR 410-200-0415) effective the date of birth through the end of the month in which the child turns one year of age, unless:
(A) The child dies;

(B) The child is no longer a resident of Oregon; or

(C) The child's representative requests a voluntary termination of the child's eligibility.

(c) A new application or request for coverage is not required for an AEN.

(d) An AEN is entitled to assumed eligibility without providing a Social Security Number (SSN). An SSN is required to maintain coverage after the assumed eligibility period ends.

(2) Continuous Eligibility:

(a) The Continuous Eligibility (CE) period is the period of time an individual who is determined eligible for an HSD medical benefit shall maintain coverage despite changes in circumstance that may otherwise preclude eligibility, with consideration of exceptions described in section (2)(b);

(b) Coverage may be terminated during the CE period in the following circumstances:
(A) The individual is no longer an Oregon resident;

(B) The individual dies;

(C) The individual or someone authorized to act on their behalf requests voluntary termination of eligibility;

(D) The agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of agency error or fraud, abuse, or perjury attributed to the individual or someone authorized to act on their behalf; or

(E) For recipients of the MAGI Expanded Adult Program (OAR 410-200-0436), the program ends.

(c) The CE period is established when an individual is determined eligible for HSD medical benefits with no outstanding requests for information, as follows:
(A) At initial approval of eligibility, the CE period begins on the first of the month in which the individual established a Date of Request (DOR);

(B) When approved for renewal of eligibility, the new CE period begins on the first of the month following the renewal due-date.

(d) The length of the CE period is based on age and program eligibility, as follows:
(A) Children under six (6) years of age are entitled to CE through the end of the month of their sixth (6) birthday or twenty-four (24) months, whichever is later;

(B) Except for individuals eligible for OHP Bridge - Basic Health Program, individuals age six (6) and above are entitled to twenty-four (24) months of CE.

(C) Individuals who are eligible for OHP Bridge - Basic Health Program are entitled to twelve (12) months of coverage in the program as long as they continue to meet non-financial eligibility criteria for the program described in OAR 410-200-0438 (2)(a) and (d) and (3).

(e) An individual's benefits may be adjusted during the continuous eligibility as long as the adjustment does not result in the reduction or termination of coverage;

(f) If an individual's eligibility is redetermined during the continuous eligibility period and they no longer meet financial eligibility requirements for any HSD Medical Program of the same or better benefit, they shall retain coverage through the program with the uppermost income eligibility threshold for which the individual meets non-financial eligibility requirements;

(g) If an individual's eligibility is redetermined during the continuous eligibility period and they no longer meet financial or non-financial eligibility requirements for any HSD Medical Program of the same or better benefit, they shall retain coverage through the Parent and Caretaker Relative program (OAR 410-200-0420).

(3) Protected Eligibility:

(a) Except for those individuals eligible for and receiving OHP Bridge - Basic Health Program benefits, individuals who are eligible for and receiving any HSD Medical Program benefits for any portion of their pregnancy are entitled to protected eligibility for the duration of the pregnancy and the postpartum eligibility period;

(b) The postpartum eligibility period is:
(A) Except as described in subsection (3)(b)(B), the postpartum eligibility period is twelve (12) calendar months following the month in which the pregnancy ends;

(B) For individuals who do not meet the citizen and non-citizen status requirements, who are eligible for and receiving Citizenship Waived Medical (CWM) Plus coverage for any portion of their pregnancy, the postpartum eligibility period is the two (2) calendar months following the month in which the pregnancy ends.

(c) Benefits may not be terminated or reduced during a period of protected eligibility unless:
(A) The individual is no longer an Oregon resident;

(B) The individual dies;

(C) The individual or someone authorized to act on their behalf requests a voluntary termination of eligibility; or

(D) The agency determines that eligibility was erroneously granted at the most recent determination, redetermination or renewal of eligibility because of agency error or fraud, abuse, or perjury attributed to the individual or someone authorized to act on their behalf.

Statutory/Other Authority: ORS 411.095, 411.402, 411.404, 413.038, 414.025 & 414.534

Statutes/Other Implemented: ORS 411.095, 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

Disclaimer: These regulations may not be the most recent version. Oregon may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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