APD MAGI Manual
Updated 10/1/19
C. Due Process
DURING THE COVID-19 EMERGENCY PERIOD, THIS SECTION IS OBSOLETE.
1. Important Information About Due Process and the OHP 7210
The OHP 7210 should be given to all individuals who apply for APD programs for the first time unless the application is a result of a ONE referral, or MAGI eligibility has otherwise already been determined within the last 90 days.
Due process is not necessary if APD benefits are reduced or closed and any of the following are true:
- The client fails to cooperate in the annual redetermination process
- The client fails to provide requested verification or information
- The client fails to pursue assets or other medical insurance
- The client refuses to assign medical rights
- The reduction or closure is the result of a change that the client failed to report timely
- The client has been referred to branch 5503 within the last 90 days
- Unable to locate
- Out of state
- Request to close benefits
Many 7210 due process applications are not processed because they are incomplete or are not emailed to the correct address. When 5503 receives an incomplete 7210, it will be returned to the sending branch for completion. Please make sure ALL pages of 7210 are accounted for and are facing the same direction.
Due process applications should be emailed to 5503.APDreferrals@state.or.us. Please review for the following items prior to emailing:
- Make sure the 7210 is completed - use the newest version on forms server
- Make sure the 7210 is signed under STEP 6 (page 20)
- Make sure income and deductions are listed on the 7210 for all household members
- Make sure the residency box is checked for each person on the application - question #7 under STEP 1 (page 2)
- Make sure the pregnancy question is answered for any female primary applicant - questions #24 and #25 under STEP 1 (page 3), and question #1 under STEP 4 (page 15)
- If the client is a caretaker relative, make sure question #33 is answered under STEP 1 (page 4) or question #16 under STEP 2
- Make sure the client is listed as the primary contact unless the client is a child, in which case the parent or guardian should be listed as the primary contact
- If there are additional household members or other individuals listed in the tax filing section for the applicant (whether they are in the household or not), make sure they are listed and all appropriate information included on the application
- Make sure tax question #26 under STEP 1 is answered for the primary applicant and question #9 under STEP 2 for everyone included on the application
- Make sure that DUE PROCESS is written or otherwise appears on the 7210
- Scan and email completed 7210 to: 5503.APDreferrals@state.or.us
- REMEMBER, if you are a COG, AAA, or other partner employee, make sure to use the proper encryption when emailing the 7210
- In the subject line of the email type: DUE PROCESS 7210
- Please make sure to add the following information to the body of the email:
- SSN
- Prime number
- Client name
- DOB
- Branch number
The due process 7210s will be reviewed for completion. Again, if not complete, they will be returned to local worker for completion. Local staff will need to get 7210 completed and emailed back to 5503.APDreferrals@state.or.us in order to have it processed.
DO NOT have client mail a 7210 labeled as due process directly to 5503 - it will not be processed timely, and in some cases, it may actually be returned to the originating branch to resubmit through the proper channel.
If you have not received an ACCESS narrative from 5503 within 90 days of submission of the 7210, email 5503.APDreferrals@state.or.us. Provide them with the date the 7210 was emailed to 5503 and include the digital copy of the 7210. 5503 will research the 7210 and reply with their determination.
IMPORTANT - if your specific scenario isn't addressed, or if you experience problems with the instructions, email 5503.APDreferrals@state.or.us
2. Procedure - Benefit Reduction (OSIPM to QMB/SMB/SMF or QMB to SMB/SMF)
The federal reporting requirement referenced in section A.2 of this worker guide only applies when individuals are denied or lose eligibility for all Medicaid programs. This means that a referral to Branch 5503 is not necessary prior to reducing benefits for clients that do not have potential MAGI eligibility. The requirement to review for MAGI programs prior to reducing OSIPM or QMB benefits remains (see OAR 461-170-0130); however APD/AAA staff will screen individuals for the three MAGI programs available to Medicare recipients and those 65 or older (Pregnant Woman, Parent/Caretaker Relative, and Child). If the basic screening outlined below reveals potential MAGI eligibility, only then will APD/AAA staff send out a pending notice with the accompanying 7210. Screening Medicare recipients or those age 65 or older for MAGI can be completed quickly by gathering the following information from the client:
- Is the individual pregnant?
- Is the individual a parent or other "caretaker relative" of a child living in the home who is one of the following:
- Under the age of 18, or
- Age 18 in high school or equivalent vocational or technical training that will be completed before the child turns 19
- Note: For MAGI purposes, "caretaker relative" means a relative of a child described above by blood, adoption, or marriage with whom the child is living who assumes primary responsibility for the child's care and who is one of the following:
- The child's father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece;
- The spouse of the parent or relative even after the marriage is terminated by death or divorce;
- An individual who is a relative of the child based on blood, including those of half-blood, adoption, or marriage
- Is the individual 18 years-old or younger?
If the answer to all questions is no, the individual is not eligible for MAGI and no 7210 is necessary. Send a timely reduction notice (see Worker Guide G. 9, Decision Notice Preparation Tips for decision notice language) and narrate the conversation and the result of the screening.
Example 1: The only MAGI programs available to an individual with Medicare are the MAGI Pregnant Woman, MAGI Parent or Other Caretaker Relative, or MAGI Child programs. Wkr contacted individual on this date and confirmed that he/she receives Medicare but is neither pregnant, the parent or other caretaker relative of a dependent child under the age of 19 living in the home, nor under the age of 19. Individual is not eligible for MAGI Medicaid programs.
Example 2: The only MAGI programs available to an adult age 65 or older are the MAGI Pregnant Woman and MAGI Parent or Other Caretaker Relative programs. Wkr contacted individual on this date and confirmed that he/she is age xx and is neither pregnant nor the parent or other caretaker relative of a dependent child under the age of 19 living in the home. Individual is not eligible for MAGI Medicaid programs.
If the answer to any of the above is yes:
Remember: You cannot screen out individuals ages 0 - 64 who are not receiving Medicare; these individuals must be sent a 7210 with a pending notice.
3. Procedure - Closure of OSIPM/OSIPM and MSP - No Services
If the closure is the result of a change that was not reported timely, benefits can be closed with 10-day or timely notice, no due process is needed. See Worker Guide G. 9, Decision Notice Preparation Tips for decision notice language. Note: Workers should still provide the individual with a 7210 with instructions to mail it to the address listed on the application. Do not pend for return of the 7210 prior to closing benefits.
If the closure is a result of a change that was reported timely, and there has been no MAGI determination within the last 90 days, begin due process as outlined below:
Due process instructions:
- Send or give the client a date-stamped 7210 with a 539H or DHS 210A
- Cross out the return mailing address and fax number on the 7210 (page #5) and remind the client to complete, sign and return the 7210 to the local office - if they send it directly to OHP Customer Service, the application will not be processed.
- LEAVE THE EXISTING CASE OPEN
- Write DUE PROCESS-LOSS OF OSIPM in black ink on the top of the 7210
- If using the 539H, check the Other box under 1. Verification we need for medical assistance or services, add See attached and include the 539H attachment.
- If using the 210A, write or type See attached in the Description of needed information or action field, and attach a note with the following language: You must be evaluated for all Medicaid programs offered by the State of Oregon. In order to do this, we need some additional information which we will provide to the Oregon Health Authority. Please complete the enclosed application as soon as possible, but no later than the date listed on the attached Notice of Information of Verification Needed, so that OHA can determine whether or not you qualify for other Medicaid programs.
- Allow 10 business days from the date the pending notice is mailed for return of the 7210 to the APD/AAA branch. The worker should only allow more than 10 business days if circumstances require more time (e.g. the individual will be out of town)
- Create a tickler in ACCESS so you will know if the 7210 is not returned
- If the 7210 is returned:
- Scan and email the 7210 to 5503.APDreferrals@state.or.us (if the 7210 is incomplete, it will be returned to local staff for completion)
- In the email subject line type: DUE PROCESS 7210
- Please make sure to add the following information to the body of the email:
- SSN
- Prime number
- Client name
- DOB
- Branch number
- If 5503 determines that the client is MAGI eligible:
- 5503 will narrate eligibility determination in Oregon ACCESS. MAGI start date and OSIPM end date will also be narrated
- 5503 will end OSIPM and open MAGI - no decision notice is required as the benefit level does not change
- If 5503 determines the client is NOT MAGI eligible:
- 5503 will narrate eligibility determination in Oregon ACCESS
- 5503 will send MAGI denial notice, which includes a referral to the exchange to find a qualified health plan
- Local APD/AAA office will send the timely OSIPM closure notice and integrate the closure, See Worker Guide G. 9, Decision Notice Preparation Tips for decision notice language.
- If the 7210 is not returned:
- Send a closure notice citing the original reason for closing the APD medical case. See Worker Guide G. 9, Decision Notice Preparation Tips for decision notice language.
- If the 7210 is returned after the deadline:
- In this case, the deadline on the 210A or 539H may only be waived for good cause – good cause is restricted to situations where circumstances beyond the individual’s control caused the delay (see OAR 461-115-0190)
- If no good cause:
- The closure stands and due process is not needed since the individual failed to cooperate
- Cross out, white-out, or otherwise remove the DUE PROCESS-LOSS OF OSIPM language from the top of the 7210 and mail it to the return mailing address on the 7210 (bottom of page #1, #20 and #23)
- If good cause is granted, advise the individual to disregard the closure notice, reopen the benefits, and begin again at step 7.
- If the individual requests additional time to return the 7210 prior to the deadline listed on the 210A or 539H, the deadline can be extended if the local office deems it necessary
- If the branch agrees to extend the deadline, a new 210A or 539H with a new deadline must be sent - begin again at step 7 if the 7210 is returned by the deadline
- If an extension was not granted, or if it was but the 7210 was not returned by the new deadline and an extension to that deadline was not granted, send a timely closure notice citing the original reason for the APD medical ineligibility. See Worker Guide G. 9, Decision Notice Preparation Tips for decision notice language.
- If the 7210 is returned after the new deadline, the closure stands and due process is not needed - cross out, white-out, or otherwise remove the DUE PROCESS-LOSS OF OSIPM language from the top of the 7210 and mail it to the return mailing address on the 7210 (bottom of page #1, #20 and #23)
- If an extension is requested after the deadline listed on the 210A or 539H:
- In this case, the deadline on the 210A or 539H may only be waived for good cause – good cause is restricted to situations where circumstances beyond the individual’s control caused the delay (see OAR 461-115-0190)
- If no good cause, the closure stands and due process is not needed since the individual failed to cooperate
- If good cause is granted, advise the individual to disregard the closure notice, mail a new 210A or 539H with a new deadline, reopen the benefits, and begin again at step 7.
4. Procedure - Closure of OSIPM - Service Case
If the client is losing OSIPM because he/she is no longer eligible for services (e.g. doesn't meet SPL or NF level of care, is disqualified due to a transfer of resources, or didn't pay liability) and the case is closing rather than being reduced:
- Review for State Plan Personal Care (SPPC)
- If eligible for SPPC, open SPPC services and send a timely notice to reduce from services to SPPC
- Note: If the client would be over income for OSIPM without services, reduce income to zero to prevent case from going NA
- If not eligible for SPPC, send a timely closure notice and close the services
- Leave the medical open until due process is completed if there has been no MAGI determination within the last 90 days
- If the 7210 is not returned or the individual otherwise declines a MAGI review, close the SPPC (if applicable) and OSIPM with timely notice
- If the 7210 is returned and due process is completed:
- If the client is eligible for MAGI and SPPC:
- 5503 will narrate eligibility determination in Oregon ACCESS. MAGI start date and OSIPM end date will also be narrated
- 5503 will end OSIPM and open MAGI - no decision notice is required as the benefit level does not change
- Once that's done, open a brand-new, separate, service-only case (OSV). Do not convert the existing OSIPM case to OSV. See APD-AR-15-028 for more information about coding these cases
- If the client is not eligible for MAGI:
- 5503 will narrate the eligibility determination in Oregon ACCESS
- 5503 will send a MAGI denial notice, which includes a referral to the exchange to find a qualified health plan
- Local APD/AAA office will send the timely OSIPM closure notice and integrate the closure, See Worker Guide G. 9, Decision Notice Preparation Tips for decision notice language.
- If the client was receiving SPPC services in the interim, send a timely notice to close the SPPC services
Important: If the individual is ineligible for OSIPM because they are no longer eligible for Services and they file a timely hearing request, the person is contesting both the Service and the Medicaid decisions. If the individual requests continuing benefits, both benefits must remain open.
If the OSIPM closure has nothing to do with services, for example, if the client is over resources for OSIPM but still service eligible, then leave both services and medical open until due process is completed.
Click here for due process instructions.
If the closure is the result of a change that was not reported timely, benefits can be closed with 10-day or timely notice, no due process is needed. See Worker Guide G. 9, Decision Notice Preparation Tips for decision notice language. Note: Workers should still provide the individual with a 7210 with instructions to mail it to the address listed on the application. Do not pend for return of the 7210 prior to closing benefits.
5. Procedure - Reduction of OSIPM to QMB/SMB/SMF - Service Case
If the client is losing OSIPM because he/she is no longer eligible for services (doesn't meet SPL or NF level of care or is disqualified due to a transfer of resources), 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:
- Is the individual pregnant?
- Is the individual a parent or other “caretaker relative” of a child living in the home who is one of the following?
- Under the age of 18
- Age 18 in high school or equivalent vocational or technical training that will be completed before the child turns 19
- Note: For MAGI purposes, “caretaker relative” means a relative of a child described above by blood, adoption, or marriage with whom the child is living who assumes primary responsibility for the child’s care and who is one of the following:
- The child’s father, mother, grandfather, grandmother, brother, sister, stepfather, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece
- The spouse of the parent of relative, even after the marriage is terminated by death or divorce
- An individual who is a relative of the child based on blood, including those of half-blood, adoption, or marriage
- Is the individual 18 years old or younger?
- If the answer toall questions is no:
- The individual is not potentially eligible for MAGI
- No 7210 is necessary
- Send a timely closure notice to end services
- Send a timely reduction notice to reduce OSIPM to QMB/SMB/SMF (see Worker Guide G. 9, Decision Notice Preparation Tips for decision notice language) and narrate the conversation and the result of the screening.
- If the answer to any of the questions is yes:
- Complete due process - see section C.3 for due process instructions.
- Keep the OSIPM open and review for SPPC eligibility
- If SPPC-eligible, reduce the services to SPPC with timely notice
- If not SPPC-eligible, close the services with timely notice
- If the individual is eligible for MAGI:
- 5503 will narrate eligibility determination in Oregon ACCESS. MAGI start date and OSIPM end date will also be narrated
- 5503 will end OSIPM and open MAGI - no decision notice is required as the benefit level does not change
- If SPPC-eligible, open a brand new, separate service-only (OSV) case- do not convert the existing OSIPM case to OSV - see APD-AR-15-028 for more information about coding these cases
Important: If the individual is ineligible for OSIPM because they are no longer eligible for Services and they file a timely hearing request, the person is contesting both the Service and the Medicaid decisions. If the individual requests continuing benefits, both benefits must remain open.
If the client is losing OSIPM for other reasons but would otherwise remain service eligible:
- Screen the individual for potential MAGI eligibility as instructed above
- If after screening you determine there is no potential MAGI eligibility, send timely notices to reduce medical and close services (for services, use Service Closure, Situation #1)
- If after screening you have determined that there is potential MAGI eligibility:
- Leave the services open until due process has been completed. See section C.3 for due process instructions.
- If MAGI-eligible:
- 5503 will narrate eligibility in Oregon ACCESS, including the MAGI start date and OSIPM end date
- 5503 will end OSIPM and open MAGI, no decision notice is required since the benefit level will not change
- Convert the APD services to K-Plan services in CA/PS effective the date the MAGI is approved
- Open a brand-new, separate service-only case (OSV) – do not convert the existing OISPM case to OSV. See APD-AR-15-028 for information about coding these cases.
- If not MAGI-eligible, the 7210 was not returned, or the individual otherwise declined a MAGI determination:
If the reduction is the result of a change that was not reported timely, medical benefits can be reduced with a timely notice, no due process is needed. Send a timely notice to close services using Service Closure, Situation #1 from the Decision Notice Preparation Tips worker guide.
See Worker Guide G. 9, Decision Notice Preparation Tips for the medical decision notice language.
6. Procedure - Closure of MSP-Only Case
If the closure is the result of a change that was not reported timely, benefits can be closed with a 10-day or timely notice, no due process is needed. See Worker Guide G. 9, Decision Notice Preparation Tips for decision notice language. Note: Workers should still provide the individual with a 7210 with instructions to mail it to the address listed on the application. Do not pend for return of the 7210 prior to closing benefits.
If the closure is a result of a change that was reported timely, and there has been no MAGI determination within the last 90 days, complete due process. Click here for instructions, except make the following changes:
- Please write DUE PROCESS - LOSS OF MSP in black ink on the top of the 7210; or
- If the client is ineligible for QMB/SMB/SMF because he/she is no longer eligible for Medicare, write DUE PROCESS - LOSS OF MSP AND LOSS OF MEDICARE in black ink on the top of the 7210
- In the email subject line type: DUE PROCESS 7210 - LOSS OF MSP (add AND LOSS OF MEDICARE if applicable)
- Replace OSIPM with MSP where otherwise applicable
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