Current through Register Vol. 63, No. 9, September 1, 2024
(1) Eligibility is
evaluated by reviewing the financial and non-financial information for the
applicable budget months. The budget month is established as follows.
(a) For new applicants, the budget month is:
(A) The initial budget month is the month in
which the Date of Request (DOR) is established; or
(B) If ineligible in the initial budget
month, the agency shall evaluate eligibility for the subsequent
month.
(b) For
retroactive medical, the budget month is the month in which the applicant
received medical services for which they are requesting payment.
(c) For a current MAGI Medicaid/CHIP
beneficiary, the budget month is:
(A) At
renewal, the month in which a renewal response is received by the
agency;
(B) The month a change that
affects eligibility is reported; or
(C) The month the individual ages off a
medical program.
(2) MAGI and MAGI-based income not
specifically excluded is countable, and its value is used in determining the
eligibility and benefit level of an applicant or beneficiary.
(3) MAGI and MAGI-based income is considered
available on the date it is received or the date a member of the EDG has a
legal right to the payment and the legal ability to make it available,
whichever is earlier, except as follows:
(a)
Income usually paid monthly or on some other regular payment schedule is
considered available on the regular payment date if the date of payment is
changed because of a holiday or weekend;
(b) Income withheld or diverted at the
request of an individual is considered available on the date the income may
have been paid without the withholding or diversion;
(c) An advance or draw of earned income is
considered available on the date it is received.
(4) For all HSD Medical Programs except OHP
Bridge - Basic Health Program, financial eligibility is evaluated for the
initial budget month by comparing the combined total of each EDG member's
countable MAGI-based income to the income standards for the appropriate family
size. Countable MAGI-based income is determined as follows:
(a) For EDG members with ongoing income (the
income has not started, changed, or ended in the month being evaluated), the
agency shall evaluate eligibility based on converted income. Converted income
is calculated by considering the average amount of representative income
received per pay period, then converting to a monthly amount using the
following conversion standards:
(A) Average
weekly income is multiplied by 4.3;
(B) Average bi-weekly income is multiplied by
2.15;
(C) Average twice-monthly
income is multiplied by 2
(D) For
ongoing income received less frequently than monthly (i.e. quarterly), the
payment amount shall be divided by the appropriate number of months to arrive
at a monthly average.
(b) For EDG members whose income started or
ended in a month being evaluated for eligibility, or changed such that income
prior to the month being evaluated is not representative of current or future
months:
(A) For income expected to be received
monthly or more frequently, the agency shall evaluate initial budget month
eligibility by combining the actual income received and expected to be received
in the budget month. Income is then converted to an ongoing amount using the
methodology described in subsection (4)(a) of this part for ongoing
eligibility.
(B) For income
expected to be paid on a regular basis less often than monthly, income is
converted as described in subsection (4)(a)(D) of this part for budget month
and ongoing eligibility.
(5) If ineligible under section (4) because
the MAGI-based income is over the applicable HSD Medical Program income
standard based on family size, MAGI income shall be annualized using the
requirements of 26 CFR §1.36 B-1(e) for the calendar year in which medical
has been requested.
(a) For all MAGI
Medicaid/CHIP programs, if the annual income is at or below 100 percent FPL),
income shall be divided by 12 to derive a monthly amount and applied to the
budget month for initial and ongoing eligibility.
(b) For OHP Bridge - Basic Health Program, if
the annual income is between 133 and 200 percent FPL, that amount shall be used
in the eligibility determination.
(6) If ineligible under sections (4) or (5)
of this rule, the agency shall evaluate eligibility for the subsequent month
using the methodology described in section (4) of this rule. If eligible, the
effective date of eligibility is established as described in HSD Medical
Programs - Effective Dates (OAR
410-200-0115).
(7) Financial eligibility for retroactive
months (see OAR 410-200-0130) is first evaluated
in accordance with section (4) of this rule. If a conversion of ongoing income
results in ineligibility, the agency shall consider the actual countable income
received in the retroactive month. If eligible, the effective date of
eligibility is established as described in HSD Medical Programs - Effective
dates (OAR 410-200-0115).
(8) In the following scenarios, an
individual's countable income may be reduced by an amount equivalent to five
percentage points of the FPL based on the applicable family size:
(a) A child who is ineligible for MAGI
Medicaid programs (MAGI Child (OAR
410-200-0415), MAGI Parent or
Caretake Relative (OAR
410-200-0420), MAGI Pregnant
Woman (OAR 410-200-0425)) and may otherwise
be eligible for MAGI CHIP (OAR
410-200-0410); if the countable
income reduced by five percentage points of the FPL is within the income
standard for a MAGI Medicaid program, the individual meets the financial
eligibility for that program.
(b)
Allowable Reduction of Countable Income for all HSD Medical Programs, except
OHP Bridge - Basic Health Program. If the countable income, when it is reduced
by five percentage points of the FPL, is within the income standard for any HSD
Medical Program, then the individual meets the financial eligibility
requirements for that program. However, the five percentage point reduction is
not used to determine financial eligibility for OHP Bridge - Basic Health
Program.
Statutory/Other Authority: ORS
411.402,
411.404 &
413.042
Statutes/Other Implemented: ORS
411.400,
411.402,
411.404,
411.406,
411.439,
411.443,
413.032,
414.025,
414.231, 414.447 &
414.706
