Current through Register Vol. 63, No. 3, March 1, 2024
(1) This rule sets out additional
restrictions on the eligibility of residents of public institutions for
programs covered by Chapter 461 of the Oregon Administrative Rules.
(2) Definition of a "resident of a public
institution".
(a) An individual living in a
public institution (see section (3) of this rule) who is:
(A) Confined involuntarily in a local, state
or federal prison, jail, detention facility, or other penal facility, including
an individual being held involuntarily in a detention center awaiting trial or
an individual serving a sentence for a criminal offense;
(B) Residing involuntarily in a facility
under a contract between the facility and a public institution
where, under the terms of the contract, the facility is a public
institution;
(C) Residing
involuntarily in a facility that is under governmental control;
(D) Receiving care as an outpatient while
residing involuntarily in a public institution; or
(E) In the OSIPM and QMB programs, no longer
a resident of the public institution during a temporary period
of hospitalization in a medical institution outside of the correctional
facility.
(b) An
individual is not considered a
resident of a public
institution when:
(A) The individual
is released on parole, probation, or post-prison supervision;
(B) The individual is on home- or
work-release, unless the individual is required to report to a public
institution for an overnight stay;
(C) The individual is voluntarily residing in
a supervised community residential facility and all of the following are true:
(i) Residents are not precluded from working
outside the facility in employment available to individuals who are not under
justice system supervision;
(ii)
Residents can use community resources such as libraries, grocery stores,
recreation and education at will, notwithstanding any house rules such as a
requirement to sign in and out, curfews, or hours during which the residence is
closed or locked; and
(iii)
Residents can seek health care treatment in the broader community to the same
or similar extent as other Medicaid enrollees in the state.
(D) The individual is staying
voluntarily in a detention center, jail, or county penal facility after their
case has been adjudicated and while other living arrangements are being made
for the individual; or
(E) The
individual is in a public institution pending other
arrangements as defined in 42 CFR 435.1010.
(3) A "public
institution" is any of the following:
(a) A
"state hospital" (see ORS
162.135).
(b) A local correctional facility (see ORS
169.005): a jail or prison for
the reception and confinement of individuals that is provided, maintained and
operated by a county or city and holds individuals for more than 36
hours.
(c) A Department of
Corrections institution (see ORS
421.005): a facility used for
the incarceration of individuals sentenced to the custody of the Department of
Corrections, including a satellite, camp, or branch of a facility.
(d) A youth correction facility (see ORS
162.135):
(A) A facility used for the confinement of
individuals placed in the legal or physical custody of the youth authority,
including a secure regional youth facility, a regional accountability camp, a
residential academy and satellite, and camps and branches of those facilities;
or
(B) A facility established under
ORS 419A.010 to
419A.020 and
419A.050 to
419A.063 for the detention of
individuals pursuant to a judicial commitment or order.
(4) Definition of serious mental
illness. An individual has a serious mental illness if the individual has been
diagnosed by a psychiatrist, a licensed clinical psychologist or a certified
non-medical examiner as having dementia, schizophrenia, bipolar disorder, major
depression or other affective disorder or psychotic mental disorder other than
a substance abuse disorder and other than a disorder that is caused primarily
by substance abuse.
(5) An
individual who resides in a state hospital (see subsection
(3)(a) of this rule), meets the definition of having a serious mental illness
(see section (4) of this rule), and applies for medical assistance between 90
and 120 days prior to the expected date of the person's release from the
state hospital may be found eligible for medical assistance.
If the individual is determined to be eligible, the effective date of the
individual's medical assistance is the date the individual is no longer a
resident of the institution.
(6) In
the OSIPM and QMB programs, except as provided for in section (7) of this rule,
an individual who is at least 21 years of age and less than 65 years of age who
becomes a resident of a state hospital has medical benefits
suspended. When an individual with suspended medical benefits is no longer a
resident of the state hospital, or when the individual is
admitted to a medical institution outside of the state
hospital for a period of hospitalization, medical benefits are
reinstated effective the first day the individual is no longer a
resident.
(7) An individual
residing in a state hospital may be eligible for OSIPM and QMB
program benefits if the individual meets the requirements of one of the
following subsections:
(a) The individual is
65 years of age or older.
(b) The
individual receives a Certificate of Need for Services from the
State-authorized agency, and meets one of the following:
(A) The individual is under 21 years of
age.
(B) The individual is 21 years
of age, received a Certificate of Need for Services from the State-authorized
agency, and received those services immediately before reaching age 21. Except
as provided for in subsection (a) of this section, eligibility ends at age
22.
(8) For
all programs covered under chapter 461 of the Oregon Administrative Rules:
(a) Except as provided otherwise in this
rule, a resident of a public institution (see section (2) of
this rule) is not eligible for benefits.
(b) Except as provided otherwise in this
rule, if a pregnant individual receiving medical assistance through the OSIPM
program becomes a resident of a public institution, their
medical benefits are suspended. When the Department learns the individual is no
longer a resident of a public institution, their medical
benefits are reinstated - effective on the first day they are no longer a
resident of a public institution - if they are still in their
protected period of eligibility under OAR 461-135-0010.
(c) If an individual receiving medical
assistance through the OSIPM or QMB programs becomes a resident of a
public institution at a correctional facility (see subsections (3)(b)
through (3)(d) of this rule), medical benefits are suspended during the
incarceration period.
(d) In the
OSIPM and QMB programs:
(A) When the
Department learns the individual is no longer a resident of a public
institution within 12 calendar months of the change, suspended
benefits may be restored, effective the first day the individual was no longer
a resident of a public institution.
(B) When the Department learns the individual
has been admitted to a hospital outside of the public
institution for a period of hospitalization, suspended benefits may be
restored effective the first day of the period of hospitalization.
(C) When the date benefits are reinstated is
prior to the individual's eligibility renewal date, the eligibility renewal
date will be maintained.
(D) When
the date benefits are reinstated is after the individual's eligibility renewal
date, eligibility must be redetermined immediately after benefits are
restored.
(9)
In the GA and SNAP programs, in addition to the other provisions of this rule,
a resident of a public institution released from a
public institution on home arrest and required to wear an
electronic device to monitor their activity, is ineligible for benefits if the
correctional agency provides room and board to the individual.
(10) In the GA program, when an individual
becomes a resident of a public institution:
(a) Housing assistance payments may continue
for one calendar month following the month the individual became a
resident of a public institution if the following are true:
(A) The Department can determine that the
individual will no longer be a resident of a public
institution before the end of the calendar month following the month
the individual became a resident of a public institution,
and
(B) The individual's housing
arrangement is still available.
(b) When the individual will no longer be a
resident of a public institution after the end of the calendar
month following the month the individual became a resident of a public
institution, or when the date the individual will no longer be a
resident of a public institution is not known, housing
assistance payments will be closed effective the end of the notice
period (see OAR 461-175-0050) for a timely continuing benefit
decision notice (see OAR 461-001-0000).
Statutory/Other Authority: ORS
409.050,
411.060,
411.070,
411.404,
411.816,
412.049,
413.085,
414.685 & 412.014
Statutes/Other Implemented: ORS
409.010,
411.060,
411.070,
411.404,
411.447,
411.816,
412.014,
412.049,
414.426 &
42 CFR
435.1009
