Current through Register Vol. 63, No. 9, September 1, 2024
The effective date for starting medical benefits for an
eligible client is as follows:
(1) In
the OSIPM and QMB-DW programs:
(a) Except as
provided for in subsections (b) to (h) of this section:
(A) If the client meets all eligibility
requirements on the date of request (see OAR
461-115-0030), it is the first
day of the month that includes the date of request. An OSIPM program client who
is assumed eligible under OAR
461-135-0010(5)
meets "all eligibility requirements" for the purposes of this section as
follows:
(i) Effective the first day of the
month of the initial SSI payment if the client is age 21 or older.
(ii) Effective the first day of the month
prior to the month of the initial SSI payment if the client is under the age of
21.
(B) If the client
does not meet all eligibility requirements on the date of request, but meets
all requirements after the date of request, within the application processing
time frames of OAR 461-115-0190, it is the first
day of the month that includes the date that all eligibility requirements are
met.
(b) If the client
does not complete the application within the time period described in OAR
461-115-0190 (including the
authorized extension), the determination of an effective date requires a new
date of request.
(c) Except as
provided for in subsections (d) and (e) of this section, for a new applicant
who is a resident of a public institution (see OAR
461-135-0950) on any day of the
month during the month that the applicant is determined to meet all eligibility
requirements, the effective date is determined in accordance with subsections
(a) and (b) of this section, except that coverage is not in effect for any day
during the month that the applicant is a resident of a public
institution other than the date of incarceration and the date of
release.
(d) The effective date for
a resident of a public institution meeting the requirements of
OAR 461-135-0950 regarding
applications received by individuals with a serious mental illness is
determined in accordance with OAR
461-135-0950.
(e) The effective date for an individual
meeting the eligibility requirements of OAR
461-135-0950 regarding residents
of a state psychiatric institution is the date that all eligibility
requirements are met, including other chapter 461 eligibility requirements, if
those requirements are met within the application processing time frames of OAR
461-115-0190. Otherwise the
requirements of subsection (b) of this section apply.
(f) The effective date for a resident
of a public institution with suspended benefits that will be
reinstated is determined in accordance with OAR
461-135-0950. If benefits will
not be reinstated the resident of a public institution is
considered a new applicant and the effective date is determined in accordance
with subsection (c) of this section.
(g) The effective date for a new applicant
who is receiving Medicaid in another state on the date of request, but meets
the requirements of OAR
461-165-0030 regarding receipt
of medical benefits in another state is:
(A)
The date of request if all eligibility requirements are met on the date of
request or after the date of request, but during the month that includes the
date of request.
(B) If all
eligibility requirements are not met during the month that includes the date of
request the effective date is determined in accordance with paragraph (1)(a)(B)
and subsection (b) of this section.
(h) The effective date for an applicant
receiving Medicaid in another state prior to the date of request, but during
the month that includes the date of request, is the day following the day that
Medicaid benefits end in the other state if all eligibility requirements are
met during the month that includes the date of request. If all requirements are
not met in the month that includes the date of request the effective date is
determined in accordance with paragraph (1)(a)(B) and subsection (b) of this
section.
(2) In the
OSIPM program, if an individual has been released from a correctional
institution and is determined eligible for OSIPM, the effective date of
beginning the individual's medical assistance is the date the individual is
released from the correctional facility or the date the individual begins the
period of hospitalization outside of the correctional facility.
(3) In the QMB-BAS program, it is the first
of the month after the benefit group (see OAR
461-110-0750) has been
determined to meet all QMB-BAS program eligibility criteria and the Department
receives the required verification.
(4) In the QMB-SMB and QMB-SMF programs, it
is:
(a) The first of the month in which the
benefit group meets all program eligibility criteria and the Department
receives the required verification; or
(b) The first of the month in which the Low
Income Subsidy (LIS) information is received by the Social Security
Administration (SSA), if the SMB or SMF program application was generated by
the electronic transmission of LIS data from the SSA and the benefit group
meets all program eligibility criteria.
(5) In the REFM program:
(a) Except as provided in subsection (b) of
this section:
(A) If the individual meets all
eligibility requirements on the date of request (see OAR
461-115-0030), it is the date of
request.
(B) If the individual does
not meet all eligibility requirements on the date of request, it is the first
day following the date of request that all eligibility requirements are
met.
(b) If the
individual does not complete the application within the time period described
in OAR 461-115-0190 (including the
authorized extension), the determination of an effective date requires a new
date of request.
(6)
Retroactive eligibility is authorized under certain circumstances in some
medical programs (see paragraph (1)(a)(A) of this rule, OAR
461-135-0875, and
461-180-0140).
Statutory/Other Authority: ORS
409.010,
409.050,
411.060,
411.070,
411.404,
411.704,
411.706,
413.085,
414.685 &
414.839
Statutes/Other Implemented: ORS
409.010,
409.050,
411.060,
411.070,
411.404,
411.439,
411.447,
411.704,
411.706,
413.085,
414.685 &
414.839
