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Staff Tools | APD MAGI Manual | E. APD Referrals from 5503
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DHS home | APD
Staff Tools | APD MAGI Manual | E. APD Referrals from 5503
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Updated 10/1/20
The Hospital Presumptive Eligibility (HPE) benefit is a temporary MAGI-based Medicaid benefit for applicants who meet the financial and non-financial requirements, are under age 65, and do not receive Medicare or SSI.
The eligibility determination is made by a “qualified” hospital that has an agreement in place with the OHA and ODHS. The hospital staff collect applicant information and provide ODHS with an appropriate notice of their decision within 5 working days.
The HPE benefit begins at midnight on the day the qualified hospital determines the individual is eligible or within 5 calendar days of the individual receiving a covered medical service, whichever date is earlier.
Individuals may only receive this temporary benefit once in a 12-month period (365 days from last date previously eligible). The HPE coverage is Oregon Health Plan Plus, which includes physical, dental, vision and mental health benefits on a Fee-For Service (FFS) or “open card” basis.
The individual will still need to apply for a full MAGI determination to continue their benefits & Post-Hospital Extended Care (PHEC). The full MAGI determination is made in ONE.
If ODHS does not receive a completed 7210 before the last day of the month following the month of admission, the HPE benefit will end on that day.
*Note: Benefits will not end during the COVID-19 emergency period.
Example: Individual is approved for HPE on July 7th and does not submit a 7210; the HPE benefit ends on August 31st. If the individual receives additional services post-discharge, such as PHEC, the provider of the additional services will be able to bill for
services rendered during that time.
If ODHS receives a completed 7210 before the last day of the month following the month of admission, the HPE benefit will end on the same day the formal determination is made by ONE.
Example: Individual is approved for HPE on July 7th but sends in a completed 7210 that makes them ineligible for MAGI-based Medicaid and that application is processed on July 15th; the HPE benefit ends on July 15th. If the individual receives additional services post-discharge, such as PHEC, the provider of the additional services will be unable to bill for services due to the loss of the underlying Medicaid benefit after July 15th.
Notices/Hearing Rights
Please note that individuals do NOT receive a separate notice that their HPE benefit is ending. In the hospital, the individual receives the HPE Approval form (OHP 3263A) which serves as their notice that the benefit is temporary and will end within two months of the approval date.
In order to apply for continuing coverage, the form instructs the individual to complete and submit an OHP 7210 before the last day of the month, following the month of their admission. The denial or termination of the HPE benefit has NO related hearing rights.
If ODHS does receive a completed 7210 that results in a denial of medical benefits, the individual will receive the appropriate decision notice with related hearing rights.
IMPORTANT - if your specific scenario isn't addressed, or if you experience problems with the instructions, email OCCS.MedicalPolicy@dhsoha.state.or.us
If you are notified that an individual was approved for the Hospital Presumptive (HPE) MAGI benefit and needs to apply for services, follow the steps below:
