Or. Admin. Code § 333-004-3100

Current through Register Vol. 63, No. 11, November 1, 2024

Section 333-004-3100 - Client Enrollment into the RH Access Fund

(1) To enroll in the RH Access Fund a client must submit the following items to the clinic:

(a) A signed, completed, and dated RH Access Fund Enrollment Form that includes all information necessary to determine the client's eligibility and benefit level:

(A) Sex designated at birth;

(B) SSN, as applicable;

(C) A mailing address, as applicable;

(D) U.S. citizenship or immigration status; and

(E) Income information. Clients can be enrolled based solely on their own income, whether living with others or on their own; and

(b) Acceptable proof of U.S. citizenship and identity, as applicable.

(2) RH Access Fund Enrollment Forms may not be backdated. A client or agency that backdates a form shall be considered by the RH Program to have committed fraud.

(3) All client eligibility information must be:

(a) Reviewed by clinic staff to ensure accuracy to the best of the client's knowledge, and completeness; and

(b) Recorded in the RH Access Fund Eligibility Database.

(4) Final determination of eligibility and enrollment into the RH Access Fund is made by the RH Program based on the information recorded in the RH Access Fund Eligibility Database.

(a) An enrollee's enrollment in the RH Access Fund shall be suspended by the RH Program if it determines that the enrollee's income is above the eligibility threshold.

(b) An enrollee shall have 45 calendar days from the date of suspension to confirm their income information or the enrollee's enrollment in the RH Access Fund shall be terminated by the RH Program.

(5) The enrolling agency must retain a copy of the completed, signed Enrollment Form. Electronic copies are acceptable.

(6) The enrolling agency must retain proof of citizenship and identity provided by the enrollee, as applicable. Electronic copies are acceptable. An agency is prohibited under ORS 432.380, from making a copy of a birth certificate. For clients providing a birth certificate as proof of citizenship, only the birth certificate number and the state of issuance must be retained by the enrolling agency.

(7) Upon application, an enrollee is conferred eligibility. If, after the RH Program performs an eligibility verification process, an enrollee is deemed ineligible for coverage, they will be provided notice of their ineligibility.

(a) An enrollee may appeal this decision and request a hearing in accordance with sections (9) or (10) of this rule, depending on the basis for the ineligibility.

(b) Clients who are issued a determination of ineligibility will remain ineligible for coverage through the duration of the appeals process.

(c) The request form must be received by the RH Program within 30 calendar days after the date of termination.

(8) Enrollment in the RH Access Fund is effective for one year from the date of enrollment. The date of enrollment is the date the enrollee signed the Enrollment Form and must be on or before the first date of service for which the RH Program will be billed.

(9) If an enrollee is denied eligibility for CCare, the following procedures apply:

(a) An enrollee has the right to a contested case hearing.

(b) To be timely, a request for a hearing must be received by the Authority no later than the 60th calendar day following the date of the decision notice.

(c) In the event a request for hearing is not timely, the Authority shall determine whether the enrollee showed there was good cause, as defined in OAR 137-003-0501(7), for their failure to timely file the hearing request. In determining whether to accept a late hearing request, the Authority requires the request to be supported by a written statement that explains why the request for hearing is late. The Authority may conduct such further inquiry as the Authority deems appropriate. If the Authority finds that the enrollee has good cause for late filing, the Authority shall refer the case to the Office of Administrative Hearings (OAH) for a contested case hearing. The following factual disputes shall be referred to the OAH for a hearing:

(A) Whether the hearing request received was timely.

(B) Whether the enrollee received the notice of denial.

(C) The information included in the enrollee's statement of good cause.

(d) An enrollee who requests a hearing shall be referred to as a claimant. The parties to a contested case hearing are the claimant and the Authority.

(e) A claimant may be represented by any of the individuals identified in ORS 183.458.

(f) The Authority shall take final administrative action on a contested hearing request within the time limits set forth in 42 CFR Part 431 and Part 435 except in unusual circumstances when:

(A) The Authority cannot reach a decision because the enrollee requests a delay or fails to take a required action; or

(B) There is an administrative or other emergency beyond the Authority's control.

(g) Informal conference.

(A) The Authority and the enrollee, and their legal representative if any, may have an informal conference without the presence of an Administrative Law Judge (ALJ) to discuss any of the matters listed in OAR 137-003-0575. The informal conference may also be used to:

(i) Provide an opportunity for the Authority and the claimant to settle the matter;

(ii) Provide an opportunity to make sure the claimant understands the reason for the action that is the subject of the hearing request;

(iii) Give the claimant and the Authority an opportunity to review the information that is the basis for that action;

(iv) Inform the claimant of the rules that serve as the basis for the contested action;

(v) Give the claimant and the Authority the chance to correct any misunderstanding of the facts;

(vi) Determine if the claimant wishes to have any witness subpoenas issued for the hearing; and

(vii) Give the Authority an opportunity to review its action.

(B) The claimant may at any time prior to the hearing date request an additional informal conference with the Authority representative, which may be granted if the Authority representative finds in their sole discretion that the additional informal discussion will facilitate the hearing process or resolution of disputed issues.

(C) The Authority may provide to the claimant the relief sought at any time before the Final Order is served.

(D) Any agreement reached in an informal conference shall be submitted to the ALJ in writing or presented orally on the record at the hearing.

(h) A claimant may withdraw a hearing request at any time. The withdrawal is effective on the date it is received by the Authority or the ALJ, whichever is first. The claimant may cancel the withdrawal up to the 10th day following the date such an order is effective.

(i) Contested case hearings are closed to non-participants in the hearing; however, an enrollee may choose to have another individual present.

(j) The Authority retains final order authority.

(k) A hearing request will be dismissed by order when neither the claimant nor the claimant's legal representative, if any, appears at the time and place specified for the hearing. The order is effective on the date scheduled for the hearing. The Authority shall cancel the dismissal order on request of the enrollee upon the claimant being able to show good cause, as defined in OAR 137-003-0501(7), as to why they were unable to attend the hearing and unable to request a postponement.

(10) If an enrollee is denied eligibility for a program other than CCare, they have 60 calendar days to request a hearing and the hearing will be conducted in accordance with ORS chapter 183 and in accordance with the Attorney General's Model Rules, OAR 137-003-0501 through 137-003-0700.

Or. Admin. Code § 333-004-3100

PH 84-2020, adopt filed 12/18/2020, effective 1/1/2021; PH 188-2022, minor correction filed 09/07/2022, effective 9/7/2022

Statutory/Other Authority: ORS 413.042, ORS 414.432, ORS 431.147, ORS 431.149 & OL 2022, ch. 45, sec. 10

Statutes/Other Implemented: ORS 414.432, ORS 431.147, ORS 413.032 & OL 2022, ch. 45, sec. 10