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Staff Tools | APD MAGI Manual | A. Background and Overview
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DHS home | APD
Staff Tools | APD MAGI Manual | A. Background and Overview
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Updated 10/1/20
The Patient Protection and Affordable Care Act was signed into law by President Obama on March 23rd, 2010. One of the most significant aspects of the Affordable Care Act (ACA) was the expansion of Medicaid to groups that were not previously considered mandatory for states to cover, most notably non-disabled adults without children.
Participation in the Medicaid expansion was not mandatory, but states that opted in were guaranteed 100% funding of the new Medicaid programs for the first three years, which will decrease gradually to 90% by 2020. Oregon was one of the first states to agree to participate.
Another change was to the financial eligibility methodology for most Medicaid programs. The resource limit was eliminated, and the method for determining income eligibility was changed to the IRS-based Modified Adjusted Gross Income (MAGI) basis. In Oregon, this means that the traditional eligibility groups (household, filing, financial, need, benefit) we were accustomed to using no longer apply; instead, MAGI methodology looks at tax filing groups and taxable income. Existing Medicaid programs for the aged, blind, and disabled were largely unaffected by the ACA in that the financial eligibility methodology did not change. In other words, there are no MAGI OSIPM, QMB, SMB, or SMF programs. Oregon's MAGI Medicaid programs are as follows:
In general, the MAGI programs are the first choice for most people, but not the typical APD/AAA client. For example, with a few exceptions, people cannot qualify for MAGI programs if they have Medicare or are age 65 or older. The exceptions are pregnant women, parent or other caretaker relatives, and children with Medicare. SSI recipients cannot receive MAGI Medicaid, regardless of pregnancy or parent/caretaker status - OSIPM is the only program available for SSI recipients in Oregon.
Even though many APD clients would not qualify for MAGI programs, we still have to rule out MAGI eligibility before reducing or closing. This is called "due process" (see below).
The term "due process" is used to describe the process of reviewing for all other Medicaid program eligibility before closing APD medical benefits. Reviewing for all medical programs isn't new; we have always been required to review for all programs before taking any kind of adverse action on existing Medicaid coverage, but the Affordable Care Act added some new dimensions to that requirement.
States that opted to participate in the Medicaid expansion project have certain requirements that were put in place to make sure everyone who wants medical insurance gets the opportunity to enroll in the most comprehensive and affordable coverage available. State Medicaid agencies are required to transmit an electronic report to the Federally Facilitated Marketplace (FFM/Account Transfer) for individuals who apply for Medicaid and are determined completely ineligible. Currently, the ONE system is the only source of electronic reporting in Oregon. The information required on the 7210 and entered into the ONE system is the only option available to meet the FFM reporting requirements at this time.
Note: Due process requirements apply to OSIPM-CAWEM benefits just as they do any other Medicaid program.
Until the COVID-19 emergency period has ended, we cannot close or reduce OSIPM or MSP benefits with a few exceptions (see the COVID-19 Worker Guide). More information will be provided once the end of the emergency period has been declared.
When necessary, screen the individual for the three MAGI programs available to Medicare recipients and those 65 or older (Pregnant Woman, Parent/Caretaker Relative, and Child) by gathering the following information:
