Or. Admin. Code § 410-200-0110

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

Section 410-200-0110 - Application and Renewal Processing and Timeliness Standards

(1) General information as it relates to application processing is as follows:

(a) An individual may apply for one or more medical programs administered by the Authority, the Department, or the Federally Facilitated Marketplace (FFM) using a single streamlined application;

(b) An application may be submitted via the Internet, the FFM, by telephone, by mail, in person, or through other commonly available electronic means;

(c) The Agency shall ensure that an application form is readily available to anyone requesting one and that community partners or Agency staff are available to assist applicants to complete the application process;

(d) If the Agency requires additional information to determine eligibility, the Agency shall send the applicant or beneficiary a request for information (RFI) which includes a statement of the specific information needed to determine eligibility and the date by which the applicant or beneficiary shall provide the required information in accordance with section (6) of this rule.

(e) If an application is filed containing the applicant or beneficiary's name and address, the Agency shall send the applicant or beneficiary a decision notice within the time frame established in section (6) of this rule;

(f) An application is complete if all the following requirements are met:

(A) All information necessary to determine all applicant's eligibility and benefit level is provided on the application for each individual in the EDG;

(B) The applicant, even if homeless, provides an address where they can receive postal mail;

(C) The application is signed in accordance with section (5) of this rule;

(D) The application is received by the Agency.

(2) General information as it relates to renewal and redetermination processing is as follows:

(a) The Authority shall review eligibility at assigned intervals, when changes are reported, and whenever a beneficiary's eligibility becomes questionable;

(b) When renewing or redetermining medical benefits, the Agency shall, to the extent feasible, determine eligibility using information found in the beneficiary's electronic account and electronic data accessible to the Agency;

(c) At renewal, if the Agency is unable to process an automated renewal, the Agency shall provide a pre-populated renewal form, referred to as an active renewal, to the beneficiary containing information known to the Agency, a statement of the additional information needed to renew eligibility, and the date by which the beneficiary must provide the required information in accordance with section (6) of this rule;

(d) The Agency shall assist applicants seeking assistance to complete the pre-populated renewal form or gather information necessary to renew eligibility;

(e) If the Agency provides the individual with a pre-populated renewal form to complete the renewal process, the individual must:

(A) Complete and sign the form in accordance with section (5) of this rule;

(B) Submit the form via the Internet, by telephone, via mail, in person, and through other commonly available electronic means, and

(C) Provide necessary information to the Agency within the time frame established in section (6) of this rule.

(3) A new application is required when:

(a) Except as described in section (4) of this rule, an individual who is not currently receiving HSD Medical Program benefits, and is not being added to an active HSD Medical Program benefits case, requests medical benefits;

(b) A child turns age 19, is no longer claimed as a tax dependent, and wishes to retain medical benefits;

(c) The Authority determines that an application is necessary to complete an eligibility determination.

(4) A new application is not required when:

(a) The Agency determines an applicant is not eligible in the month of application and:

(A) Is determining if the applicant is eligible the following month; or

(B) Is determining if the applicant is eligible retroactively (OAR 410-200-0130).

(b) Determining initial eligibility for HSD Medical Programs via Fast-Track enrollment pursuant to OAR 410-200-0505;

(c) Benefits are closed and reopened during the same calendar month;

(d) An individual's medical benefits were suspended because they became a resident of a public institution and met the requirements of OAR 410-200-0140;

(e) An individual not receiving medical program benefits is added to an existing case where any members of the individual's EDG are receiving medical program benefits;

(f) Redetermining or renewing eligibility for beneficiaries and the Agency has sufficient evidence to redetermine or renew eligibility for the same or new program;

(g) During the ninety (90) day reconsideration period for eligibility following closure:

(A) The Authority shall redetermine in a timely manner (OAR 410-200-0110) the eligibility of an individual who:

(i) Lost HSD Medical Program eligibility because they did not return the pre-populated renewal form or respond to an RFI, and did not submit the information needed to renew eligibility; and

(ii) Within ninety (90) days of the medical closure date, submits the pre-populated renewal form or provides the requested additional information.

(B) The date the pre-populated renewal form or RFI response is submitted within the ninety (90) day reconsideration period establishes a new date of request;

(C) In the event that the pre-populated renewal form is submitted within the ninety (90) day reconsideration period and an RFI is generated for which the due date lands outside of the ninety (90) day reconsideration period, a new application is not required.

(D) If the individual is found to meet HSD Medical Program eligibility based on the completed redetermination, the effective date of medical benefits is as described in OAR 410-200-0115(3) and (4).

(5) Signature requirements are as follows:

(a) Signatures accepted by the Agency may be:

(A) Handwritten;

(B) Electronic; or

(C) Telephonic.

(b) An application must be signed by one of the following:

(A) The head of household;

(B) An adult in the applicant's EDG;

(C) An authorized representative; or

(D) If the applicant is a child or incapacitated, someone age 18 or older acting responsibly for the applicant.

(c) If the original signor of an application ceases to be a member of the case, the signature of an individual described in (5(b)) of this rule is required.

(d) Hospital Presumptive Eligibility may be determined without a signature if no electronic data match with the FDSH shall be performed;

(e) At renewal, if the Agency is unable to process an automated renewal, a signature is required on the pre-populated active renewal form sent to the beneficiary.

(6) Application and renewal processing timeliness standards are as follows:

(a) At initial eligibility determination, the Agency shall inform the individual of timeliness standards, make an eligibility determination, and send a decision notice by the 45th calendar day after the Date of Request if:

(A) All information necessary to determine eligibility is present;

(B) An RFI has been issued, and the agency does not receive a response by the deadline provided; or

(C) A completed application is not received by the agency within 45 days after the Date of Request.

(b) At initial eligibility determination, the Agency may extend the 45-day period described in section (6)(a) if:

(A) The Agency must request additional information or verification, and the due date of such request extends beyond the 45th day; or

(B) There is an administrative or other emergency beyond the control of the Agency. The Agency must document the emergency;

(c) At periodic renewal of eligibility, if additional information or verification is required, the Authority shall provide the beneficiary at least thirty (30) days from the date of the renewal form to respond and provide necessary information.

(7) Individuals may apply through the FFM. If the FFM determines the individual is potentially eligible for Medicaid/CHIP or OHP Bridge, the FFM shall transfer the individual's electronic account to the Oregon Department of Human Services for eligibility determination.

(8) HSD Medical Program eligibility is evaluated in the following order:

(a) For a child applicant:

(A) Substitute Care, when the child is in Behavioral Rehabilitation Services (BRS) or in Psychiatric Residential Treatment Facility (PRTF) (OAR 410-200-0405);

(B) MAGI Parent or Caretaker Relative (OAR 410-200-0420);

(C) MAGI Pregnant Woman program (OAR 410-200-0425);

(D) MAGI Child (OAR 410-200-0415);

(E) Extended Medical Assistance (OAR 410-200-0440);

(F) MAGI CHIP (OAR 410-200-0410);

(G) FFCYM (OAR 410-200-0407);

(H) BCCTP (OAR 410-200-0400)

(b) For an adult applicant:

(A) Substitute Care (OAR 410-200-0405);

(B) MAGI Parent or Caretaker Relative (OAR 410-200-0420);

(C) MAGI Pregnant Woman (OAR 410-200-0425);

(D) FFCYM (OAR 410-200-0407);

(E) MAGI Adult (OAR 410-200-0435);

(F) EXT (OAR 410-200-0440);

(G) MAGI Expanded Adult (OAR 410-200-0436);

(H) BCCTP (OAR 410-200-0400);

(I) OHP Bridge - Basic Medicaid (OAR 410-200-0437)

(J) OHP Bridge - Basic Health Program (OAR 410-200-0438)

(K) Compact of Free Association (COFA) Dental (OAR 410-200-0445);

(L) Veteran Dental (OAR 410-200-0450).

Or. Admin. Code § 410-200-0110

DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1/30/2015; DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16; DMAP 24-2016, f. & cert. ef. 6/2/2016; DMAP 23-2020, amend filed 05/07/2020, effective 5/8/2020; DMAP 33-2020, temporary amend filed 06/29/2020, effective 7/6/2020 through 1/1/2021; DMAP 67-2020, amend filed 12/22/2020, effective 1/1/2021; DMAP 12-2023, amend filed 03/30/2023, effective 4/1/2023; DMAP 94-2024, amend filed 05/29/2024, effective 6/1/2024

Statutory/Other Authority: ORS 411.402, 411.404, 413.042 & 414.534

Statutes/Other Implemented: ORS 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