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APD Worker Guide

G.9 Decision Notice Preparation Tips

Updated 1/1/21

Disclaimer:  When preparing decision notices, you should be very careful to be sure that the situation for your specific client is accurately reflected in the notice and that you have carefully chosen all applicable rules that support your decision. You should be sure to add any rules that might be missing from these samples when your client’s situation is not the exact same situations as what these examples were designed for.

MEDICAL: Closure dot Reduction dot Denial dot Miscellaneous
SNAP: Closure dotr Reduction dot Denial
SERVICE: Closure dot Denial dot Reduction
SPECIAL NEEDS: Closure dot Reduction dot Denial
TRANSLATIONS: Spanish dot Russian dot Simplified Chinese dot Traditional Chinese dot Vietnamese dot Somali

Eligibility Issues

Medical Closure

Situation

Medicare Recipient

Non-Medicare Client

1. Whereabouts unknown - no need to refer to 5503 prior to closure (SDS 540)

 

 

We have received returned mail for this address stating you have moved and left no forwarding address.  Since we cannot locate you, we are closing your medical benefits effective mm/dd/yy. OAR 410-120-1210; 461-170-0011(3)(d)(E); 461-175-0210(2); 461-105-0020


If client was OSIPM and/or QMB-BAS add:

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.  

We have received returned mail for this address stating you have moved and left no forwarding address.  Since we cannot locate you, we are closing your medical benefits effective mm/dd/yy. OAR 410-120-1210; 461-170-0011(3)(d)(E); 461-175-0210(2); 461-105-0020

2. Move out of state (Residency) - no need to refer to 5503 prior to closure (SDS 540)

 Note: For SNAP, no notice is required when the filing group moves out of state. See 461-175-0200 and 461-175-0210

 

The Department will end your medical benefits on mm/dd/yy. You are no longer an Oregon resident. You must be a resident to receive benefits from Oregon programs. OAR 410-120-1210, 410-200-0200(1); 461-120-0010(1); 461-120-0030; 461-165-0030(2); 461-120-0050; 461-175-0210(1)(a)(A)(B)


If client was OSIPM and/or QMB-BAS add:

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.  

The Department will end your medical benefits on mm/dd/yy. You are no longer an Oregon resident. You must be a resident to receive benefits from Oregon programs. OAR 410-120-1210, 410-200-0200(1); 461-120-0010(1); 461-120-0030; 461-165-0030(2); 461-120-0050; 461-175-0210(1)(a)(A)(B)

3a. Closure of OSIPM - Client is no longer eligible for SERVICES, does not qualify for any APD medical benefits, 7210 was returned, and MAGI was denied (SDS 540)

Send a separate 540 for services. Additionally, for in-home services, send a DHS 4105 to the HCW prior to ending services.

Do not send notice and close medical until after 5503 determines eligibility for MAGI medical. If MAGI is approved, 5503 will close the APD medical case and no notice is necessary.

Your home and community-based care services were closed effective mm/dd/yy and you received a separate notice regarding this action.  Without home and community-based care services you are no longer eligible for Oregon Supplemental Income Program - Medical (OSIPM) and your benefits will be closed effective mm/dd/yy. To be eligible for OSIPM without home and community- based care services, your adjusted income must be below the program income standard. Your income of $insert income puts you over the OSIPM adjusted income standard. Your income also puts you over the adjusted income standard for the Medicare Savings Programs (QMB, SMB, SMF) that pay out-of-pocket Medicare costs. As of the above effective date, you will be responsible for your Medicare premiums, co-pays and deductibles.  You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You will receive a separate notice regarding your eligibility for other Medicaid programs offered by the Department.

OAR 410-120-1210; 461-001-0000(3); 461-155-0250; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2) and (4); 461-115-0010(1),(2),(3),(6)(7); 461-115-0020; 461-115-0230(5); 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0010; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.  Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.  

Do not send notice and close medical until after 5503 determines eligibility for MAGI medical. If MAGI is approved, 5503 will close the OSIPM case and no notice is necessary.

Your home and community-based care services were closed effective mm/dd/yy and you received a separate notice regarding this action.  Without home and community-based care services you are no longer eligible for Oregon Supplemental Income Program - Medical (OSIPM) and your benefits will be closed effective mm/dd/yy. To be eligible for OSIPM without home and community- based care services, your adjusted income must be below the program income standard. Your income of $insert income puts you over the OSIPM adjusted income standard. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You will receive a separate notice regarding your eligibility for other Medicaid programs offered by the Department.

OAR 410-120-1210; 461-001-0000(3); 461-155-0250; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2) and (4); 461-115-0010(1),(2),(3),(6)(7); 461-115-0020; 461-115-0230(5); 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0010; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

3b. Closure of OSIPM - Client is no longer eligible for SERVICES, does not qualify for any APD medical benefits, and client did not return 7210 (SDS 540)

Send a separate 540 for services. Additionally, for in-home services, send a DHS 4105 to the HCW prior to ending services.

Your home and community-based care services were closed effective mm/dd/yy and you received a separate notice regarding this action.  Without home and community-based care services you are no longer eligible for Oregon Supplemental Income Program - Medical (OSIPM) and your medical benefits will be closed effective mm/dd/yy. To be eligible for OSIPM without home and community- based care services, your adjusted income must be below the program income standard. Your income of $insert income puts you over the OSIPM adjusted income standard. Your income also puts you over the adjusted income standard for the Medicare Savings Programs (QMB, SMB, SMF) that pay out-of-pocket Medicare costs. As of the above effective date, you will be responsible for your Medicare premiums, co-pays and deductibles.  You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. On mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-001-0000(3); 461-155-0250; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345, 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0010; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540, 461-160-0550, 461-160-0551, 461-160-0552; 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.  Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

Your home and community-based care services were closed effective mm/dd/yy and you received a separate notice regarding this action.  Without home and community-based care services you are no longer eligible for Oregon Supplemental Income Program - Medical (OSIPM) and your medical benefits will be closed effective mm/dd/yy. To be eligible for OSIPM without home and community- based care services, your adjusted income must be below the program income standard. Your income of $insert income puts you over the OSIPM adjusted income standard. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. On mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-001-0000(3); 461-155-0250; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345, 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0010; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540, 461-160-0550, 461-160-0551, 461-160-0552; 461-170-0130; 461-180-0085

4. Failure to comply with annual medical review process –no referral to 5503 necessary (SDS 540)

Your medical benefits will be closed effective mm/dd/yy.  We must review your case once every 12 months to determine whether you meet the requirements for Medicaid. Your review was due by mm/dd/yy. On mm/dd/yy we requested that you fill in action - contact us to schedule an interview/complete the application we providedWe gave you until mm/dd/yy to complete this action.  You have not fill in action - contacted us/completed an interview/returned the application; therefore, we cannot determine your continuing eligibility for Medicaid.  As of the above effective date, you will be responsible for any out-of-pocket Medicare costs the Department was paying.

OAR 410-120-1210; 461-105-0020; 461-115-0230; 461-115-0430

If client was OSIPM and/or QMB-BAS add:

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.  

Your medical benefits will be closed effective mm/dd/yy.  We must review your case once every 12 months to determine whether you meet the requirements for Medicaid. Your review was due by mm/dd/yy. On mm/dd/yy we requested that you fill in action - contact us to schedule an interview/complete the application we providedWe gave you until mm/dd/yy to complete this action.  You have not fill in action - contacted us/completed an interview/returned the application; therefore, we cannot determine your continuing eligibility for Medicaid. 

OAR 410-120-1210; 461-105-0020; 461-115-0230; 461-115-0430

5. Failure to provide requested verification, no referral to 5503 is necessary (SDS 540)

On mm/dd/yy, we requested verification from you regarding insert verification type.  This information was due on mm/dd/yy. To date, we have not received this requested verification. Because we have not received this information, your medical benefits will close effective mm/dd/yy.  As of the above effective date, you will be responsible for any out-of-pocket Medicare costs the Department was paying. 

OAR 410-120-1210;, 461-105-0020; 461-115-0010(1),(2),(3); 461-115-0190(1), 461-115-0430(2),(3); 461-115-0610(1),(3); 461-115-0700

If client was OSIPM and/or QMB-BAS add:
For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

On mm/dd/yy, we requested verification from you regarding insert verification type.  This information was due on mm/dd/yy. To date, we have not received this requested verification. Because we have not received this information, your medical benefits will close effective mm/dd/yy.

OAR 410-120-1210;, 461-105-0020; 461-115-0010(1),(2),(3); 461-115-0190(1), 461-115-0430(2),(3); 461-115-0610(1),(3); 461-115-0700

6a. Closure of OSIPM-EPD for failure to make monthly participant fee, client is not eligible for any APD medical, 7210 was returned, and MAGI was denied (SDS 540)

Do not send notice and close medical until after 5503 determines eligibility for MAGI medical. If MAGI is approved, 5503 will close the APD medical case and no notice is necessary.

 

As a recipient of the Employed Person with Disabilities (EPD) program, you are required to pay a participant fee each month. Based on your income of $____, you must pay $____ each month to have EPD eligibility.  This payment is due by the 10th of each month.  You have not made your monthly payment for the month(s) of mm/yyyy. therefore, your medical benefits will close effective mm/dd/yy. As of the above effective date, you will be responsible for any out-of-pocket Medicare costs the Department was paying. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs.  You will receive a separate notice regarding your eligibility for other Medicaid programs offered by the Department.

OAR 410-120-1210; 461-001-0035; 461-135-0725; 461-160-0800; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1) and (4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0010; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

As a recipient of the Employed Person with Disabilities (EPD) program, you are required to pay a participant fee each month. Based on your income of $____, you must pay $____ each month to have EPD eligibility.  This payment is due by the 10th of each month.  You have not made your monthly payment for the month(s) of mm/yyyy; therefore, your medical benefits will close effective mm/dd/yy.  You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs.  You will receive a separate notice regarding your eligibility for other Medicaid programs offered by the Department.

OAR 410-120-1210; 461-001-0035; 461-135-0725; 461-160-0800; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1) and (4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0010; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

6b. Closure of OSIPM-EPD for failure to make monthly participant fee, client is not eligible for any APD medical, and client did not return 7210 (SDS 540)

As a recipient of the Employed Person with Disabilities (EPD) program, you are required to pay a participant fee each month. Based on your income of $____, you must pay $____ each month to have EPD eligibility.  This payment is due by the 10th of each month.  You have not made your monthly payment for the month(s) of mm/yyyy; therefore, your medical benefits will close effective mm/dd/yy. As of the above effective date, you will be responsible for any out-of-pocket Medicare costs the Department was paying. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs.  In addition, on mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-001-0035; 461-135-0725; 461-160-0800; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0010; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

As a recipient of the Employed Person with Disabilities (EPD) program, you are required to pay a participant fee each month. Based on your income of $____, you must pay $____ each month to have EPD eligibility.  This payment is due by the 10th of each month.  You have not made your monthly payment for the month(s) of mm/yyyy; therefore, your medical benefits will close effective mm/dd/yy.  You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs.  In addition, on mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-001-0035; 461-135-0725; 461-160-0800; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0010; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

7a. Closure of OSIPM - Loss of SSI, client is not entitled to any APD medical benefits, 7210 was returned, and MAGI was denied  (SDS 540)

Note: Before referring, make sure to evaluate client for ALL protected OSIPM groups (1619B, DAC, etc.)

Do not send notice and close medical until after 5503 determines eligibility for MAGI medical. If MAGI is approved, 5503 will close the APD medical case and no notice is necessary.

You are no longer eligible for Oregon Supplemental Income Program-Medical (OSIPM) effective mm/dd/yy because you no longer receive SSI benefits and your income from _____ of $______ puts you over the adjusted income standard for OSIPM. Your income also puts you over the adjusted income standard for the Qualified Medicare Beneficiary (QMB) program which pays for your Medicare premiums, co-pays, and deductibles. As of the above effective date, you will be responsible for any out-of-pocket Medicare costs the Department was paying. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs.  You will receive a separate notice about other Medicaid programs offered by the Department. 

OAR 410-120-1210; 461-001-0000(3); 461-135-0010; 461-155-0250; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

You are no longer eligible for Oregon Supplemental Income Program-Medical (OSIPM) effective mm/dd/yy because you no longer receive SSI benefits and your income from _____ of $______ puts you over the adjusted income standard for OSIPM.  You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs.  You will receive a separate notice about other Medicaid programs offered by the Department. 

OAR 410-120-1210; 461-001-0000(3); 461-135-0010; 461-155-0250; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

7b. Closure of OSIPM - Loss of SSI, client is not entitled to any APD medical benefits, and client did not return 7210  (SDS 540)

Note: Note: Before referring make sure to evaluate client for ALL protected OSIPM groups (1619B, DAC, etc.)

.

You are no longer eligible for Oregon Supplemental Income Program-Medical (OSIPM) effective mm/dd/yy because you no longer receive SSI benefits and your income from _____ of $______ puts you over the adjusted income standard for OSIPM. Your income also puts you over the adjusted income standard for the Qualified Medicare Beneficiary (QMB) program which pays for your Medicare premiums, co-pays, and deductibles. As of the above effective date, you will be responsible for any out-of-pocket Medicare costs the Department was paying. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. In addition, on mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-001-0000(3); 461-135-0010; 461-155-0250; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345, 461-120-0510(1),(4),(5),(6)(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

You are no longer eligible for Oregon Supplemental Income Program-Medical (OSIPM) effective mm/dd/yy because you no longer receive SSI benefits and your income from _____ of $______ puts you over the adjusted income standard for OSIPM.  You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. In addition, on mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs. 

OAR 410-120-1210; 461-001-0000(3); 461-135-0010; 461-155-0250; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345, 461-120-0510(1),(4),(5),(6)(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

8a. Closure of OSIPM - Client no longer meets DAC eligibility criteria due to resources, is not eligible for any other APD medical program, 7210 was returned, and MAGI was denied (SDS 540)

Do not send notice and close medical until after 5503 determines eligibility for MAGI medical. If MAGI is approved, 5503 will close the APD medical case and no notice is necessary.

Your medical benefits will end effective mm/dd/yy. You no longer qualify for Oregon Supplemental Income Program-Medical (OSIPM) as a Disabled Adult Child (DAC). In order to qualify for OSIPM as a DAC, you must meet the eligibility requirements for Supplemental Security Income (SSI) other than the fact that you are receiving your Social Security disabled adult child benefit. You now have resources which exceed the allowable resource limit of $2,000 for the SSI program; therefore, you would not qualify for SSI even if you were not receiving your disabled adult child benefit. Without this protected status, you are now over the resource limit of $2,000 for OSIPM. Your adjusted income also puts you over the income limitfor the Medicare Savings Programs (QMB, SMB, SMF) which pay for Medicare-related costs. As of the above effective date, you will be responsible for your Medicare premiums, co-pays and deductibles. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You will receive a separate notice about other Medicaid programs offered by the Department. 

OAR 410-120-1210; 461-001-0000(3); 461-135-0830(4); 461-160-0010(3); 461-160-0015(3); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1)(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

Your medical benefits will end effective mm/dd/yy. You no longer qualify for Oregon Supplemental Income Program-Medical (OSIPM) as a Disabled Adult Child (DAC). In order to qualify for OSIPM as a DAC, you must meet the eligibility requirements for Supplemental Security Income (SSI) other than the fact that you are receiving your Social Security disabled adult child benefit. You now have resources which exceed the allowable resource limit of $2,000 for the SSI program; therefore, you would not qualify for SSI even if you were not receiving your disabled adult child benefit. Without this protected status, you are now over the resource limit of $2,000 for OSIPM. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You will receive a separate notice about other Medicaid programs offered by the Department. 

OAR 410-120-1210; 461-001-0000(3); 461-135-0830(4); 461-160-0010(3); 461-160-0015(3); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1)(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

8b. Closure of OSIPM - Client no longer meets DAC eligibility criteria due to excess income and no longer receiving DAC benefits, is not eligible for any other APD medical program, and client did not return 7210 (SDS 540)

Your medical benefits will end effective mm/dd/yy. You no longer qualify for Oregon Supplemental Income Program-Medical (OSIPM) as a Disabled Adult Child (DAC). In order to qualify for OSIPM as a DAC, you must meet the eligibility requirements for Supplemental Security Income (SSI) other than the fact that you are receiving your Social Security disabled adult child benefit. You are no longer receiving Social Security disabled adult child benefits. Without this protected status, you are now over the adjusted income limit for OSIPM. Your income also puts you over the adjusted income limit for the Medicare Savings Programs which pay for Medicare out-of-pocket costs. As of the above effective date, you will be responsible for your Medicare premiums, co-pays and deductibles. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. In addition, on mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-001-0000(3); 461-135-0830(4); 461-155-0250; 461-155-0290; 461-155-0295; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

Your medical benefits will end effective mm/dd/yy. You no longer qualify for Oregon Supplemental Income Program-Medical (OSIPM) as a Disabled Adult Child (DAC). In order to qualify for OSIPM as a DAC, you must meet the eligibility requirements for Supplemental Security Income (SSI) other than the fact that you are receiving your Social Security disabled adult child benefit. You are no longer receiving Social Security disabled adult child benefits. Without this protected status, you are now over the adjusted income limit for OSIPM. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. In addition, on mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-001-0000(3); 461-135-0830(4); 461-155-0250; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

9a. Closure of OSIPM (or OSIPM and QMB) for being over income, client is not eligible for any APD medical program, 7210 was returned, and MAGI was denied (SDS 540)

Do not send notice and close medical until after 5503 determines eligibility for MAGI medical. If MAGI is approved, 5503 will close the APD medical case and no notice is necessary.

Your medical benefits will end effective mm/dd/yy. You are no longer eligible for Oregon Supplemental Income Program Medical (OSIPM) because your new income from _____ of $______ puts you over the adjusted income standard for OSIPM. Your income also puts you over the adjusted income standard for the Qualified Medicare Beneficiary (QMB) program which pays for your Medicare premiums, co-pays, and deductibles. As of the above effective date, you will be responsible for any out-of-pocket Medicare costs the Department was paying. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You will receive a separate notice about other Medicaid programs offered by the Department. 

OAR 410-120-1210; 461-001-0000(3); 461-155-0250; 461-155-0290; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

Your medical benefits will end effective mm/dd/yy. You are no longer eligible for Oregon Supplemental Income Program-Medical (OSIPM) because your new income from _____ of $______ puts you over the adjusted income standard for OSIPM. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You will receive a separate notice about other Medicaid programs offered by the Department. 

OAR 410-120-1210; 461-001-0000(3); 461-155-0250; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

9b. Closure of OSIPM (or OSIPM and QMB) for being over income, client is not eligible for any APD medical program, and client did not return 7210 (SDS 540)

Your medical benefits will end effective mm/dd/yy. You are no longer eligible for Oregon Supplemental Income Program Medical (OSIPM) because your new income from _____ of $______ puts you over the adjusted income standard for OSIPM. Your income also puts you over the adjusted income standard for the Qualified Medicare Beneficiary (QMB) program which pays for your Medicare premiums, co-pays, and deductibles. As of the above effective date, you will be responsible for any out-of-pocket Medicare costs the Department was paying.  You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. In addition, on mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-001-0000(3); 461-155-0250; 461-155-0290; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

Your medical benefits will end effective mm/dd/yy. You are no longer eligible for Oregon Supplemental Income Program-Medical (OSIPM) because your new income from _____ of $______ puts you over the adjusted income standard for OSIPM. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. In addition, on mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-001-0000(3); 461-155-0250; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

10a. Closure of OSIPM for no longer residing in an acute care hospital or nursing facility, client is over income, is not eligible for any APD medical program, 7210 was returned, and MAGI was denied (SDS 540)

Your medical benefits will end effective mm/dd/yy. You were receiving Oregon Supplemental Income Program-Medical (OSIPM) benefits for individuals residing in an acute care setting for at least 30 continuous days. Because you are no longer residing in an acute care hospital or nursing facility and are not receiving home and community-based services, your income of $______ puts you over the adjusted income standard for OSIPM. As of the above effective date, you will be responsible for any out-of-pocket Medicare costs the Department was paying.  You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You will receive a separate notice about other Medicaid programs offered by the Department. 

OAR 410-120-1210; 461-001-0000(3); 461-135-0745; 461-135-0750; 461-155-0250; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

Your medical benefits will end effective mm/dd/yy. You were receiving Oregon Supplemental Income Program-Medical (OSIPM) benefits for individuals residing in an acute care setting for at least 30 continuous days. Because you are no longer residing in an acute care hospital or nursing facility and are not receiving home and community-based services, your income of $______ puts you over the adjusted income standard for OSIPM. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You will receive a separate notice about other Medicaid programs offered by the Department. 

OAR 410-120-1210; 461-001-0000(3); 461-135-0745; 461-135-0750; 461-155-0250; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

10b. Closure of OSIPM for no longer residing in an acute care hospital or nursing facility, client is over income, is not eligible for any APD medical program, and client did not return 7210 (SDS 540)

Your medical benefits will end effective mm/dd/yy. You were receiving Oregon Supplemental Income Program-Medical (OSIPM) benefits for individuals residing in an acute care setting for at least 30 continuous days. Because you are no longer residing in an acute care hospital or nursing facility and are not receiving home and community-based services, your income of $______ puts you over the adjusted income standard for OSIPM. As of the above effective date, you will be responsible for any out-of-pocket Medicare costs the Department was paying.  You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. In addition, on mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-001-0000(3); 461-135-0745; 461-135-0750; 461-155-0250; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1)(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

Your medical benefits will end effective mm/dd/yy. You were receiving Oregon Supplemental Income Program-Medical (OSIPM) benefits for individuals residing in an acute care setting for at least 30 continuous days. Because you are no longer residing in an acute care hospital or nursing facility and are not receiving home and community-based services, your income of $______ puts you over the adjusted income standard for OSIPM. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. In addition, on mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-001-0000(3); 461-135-0745; 461-135-0750; 461-155-0250; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1)(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

11a. Closure of SMB due to a change in income or yearly change in income standards, client is not eligible for any APD medical program, 7210 was returned and MAGI was denied (SDS 540)

Do not send notice and close medical until after 5503 determines eligibility for MAGI medical. If MAGI is approved, 5503 will close the APD medical case and no notice is necessary.

Your current income puts you over the adjusted income standard for your current Medicare Savings Program, the Specified Low Income Medicare Beneficiaries (SMB) that pays your Part B Medicare premium.  You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You will receive a separate notice about other Medicaid programs offered by the Department. 

OAR 410-120-1210; 461-001-0000(3); 461-155-0295; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

11b. Closure of SMF due to a change in income or yearly change in income standards, client is not eligible for any APD medical program, 7210 was returned and MAGI was denied (SDS 540)

Do not send notice and close medical until after 5503 determines eligibility for MAGI medical. If MAGI is approved, 5503 will close the APD medical case and no notice is necessary.

Your current income puts you over the adjusted income standard for your current Medicare Savings Program, the Qualified Individuals Program (SMF) that pays your Part B Medicare premium.  You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You will receive a separate notice about other Medicaid programs offered by the Department. 

OAR 410-120-1210; 461-001-0000(3); 461-155-0295; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

11c. Closure of SMB due to a change in income or yearly change in income standards, client is not eligible for any APD medical program, and client did not return 7210 - SMB-only clients (SDS 540)

Your current income puts you over the adjusted income standard for your current Medicare Savings Program, the Specified Low Income Medicare Beneficiaries (SMB) that pays your Part B Medicare premium. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. In addition, on mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-001-0000(3); 461-155-0295; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

11d. Closure of SMF due to a change in income or yearly change in income standards, client is not eligible for any APD medical program, and client did not return 7210 - SMF-only clients (SDS 540)

Your current income puts you over the adjusted income standard for your current Medicare Savings Program, the Qualified Individuals Program (SMF) that pays your Part B Medicare premium. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. In addition, on mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-001-0000(3); 461-155-0295; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

12a. Closure of OSIPM-only for excess resources, client is not eligible for any APD medical program, 7210 was returned, and MAGI was denied (SDS 540)

Do not send notice and close medical until after 5503 determines eligibility for MAGI medical. If MAGI is approved, 5503 will close the OSIPM case and no notice is necessary.

Effective mm/dd/yy your medical benefits will end. You have resources that exceed the $2000/,$3,000 limit for the Oregon Supplemental Income Program-Medical (OSIPM). You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You will receive a separate notice about other Medicaid programs offered by the Department. 

OAR 410-120-1210; 461-160-0010(3); 461-160-0015(3); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

12b. Closure of OSIPM-only for excess resources, client is not eligible for any APD medical program, and client did not return 7210(SDS 540)

Effective mm/dd/yy your medical benefits will end. You have resources that exceed the $2000/,$3,000 limit for the Oregon Supplemental Income Program-Medical (OSIPM). You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. In addition, on mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-160-0010(3); 461-160-0015(3); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

13. Inmate of an institution - no referral to 5503 needed

To receive medical benefits you cannot be an inmate of a public institution. You are considered an inmate of a public institution. You are not eligible for any other Medicaid program. OAR 410-120-1210; 410-200-0140(1); 461-135-0950(1),(2),(3),(4),(5),(6),(7)

If OSIPM and/or QMB-BAS, add:

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

 

To receive medical benefits you cannot be an inmate of a public institution. You are considered an inmate of a public institution. You are not eligible for any other Medicaid program. OAR 410-120-1210; 410-200-0140(1); 461-135-0950(1),(2),(3),(4),(5),(6),(7)

14. Disqualifying transfer of resources

Send the SDS 0540T for services and an SDS 540 for medical if the applicant is ineligible for all medical programs. Use notice language appropriate for the applicant’s scenario (e.g. over income). Otherwise reduce to appropriate program.  Send SDS 0544 if appropriate (see the OSIP WG-7)

Medical Reduction

1a. Reduction of OSIPM to QMB benefits due to an increase in income, not potentially MAGI-eligible (SDS 540)

Your current adjusted income places you over income for Oregon Supplemental Income Program-Medical (OSIPM). The only program you qualify for is the Qualified Medicare Beneficiary program (QMB) that pays your Medicare premiums, some co-pays & deductibles. You are not eligible for the MAGI Medicaid programs because you are not pregnant, and you are over 18 or over 64 with Medicare and are not a parent or caretaker relative of a dependent child living with you.  

OAR 410-120-1210, 410-200-0415(2); 410-200-0420(3); 410-200-0425(2); 410-200-0435(4); 461-001-0000(3); 461-155-0250; 461-155-0290; 461-160-0540; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130, 461-180-0085

1b. Reduction of OSIPM to QMB benefits due to an increase in income, potentially MAGI-eligible, 7210 was returned and MAGI was denied (SDS 540)

Do not send notice and reduce medical until after 5503 determines eligibility for MAGI medical. If MAGI is approved, 5503 will take the appropriate case actions and no notice is necessary.

Your current adjusted income places you over income for Oregon Supplemental Income Program-Medical (OSIPM).  The only program you qualify for is the Qualified Medicare Beneficiary program (QMB) that pays your Medicare premiums, some co-pays & deductibles. On mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs. You will receive a separate notice regarding your eligibility for other Medicaid programs offered by the Department.

OAR 410-120-1210; 461-001-0000(3); 461-155-0250; 461-155-0290; 461-160-0540; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

1c. Reduction of OSIPM to QMB benefits due to an increase in income, potentially MAGI-eligible, and client did not return 7210 (SDS 540)

Your current adjusted income places you over income for Oregon Supplemental Income Program-Medical (OSIPM).  The only program you qualify for is the Qualified Medicare Beneficiary program (QMB) that pays your Medicare premiums, some co-pays & deductibles. On mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-001-0000(3); 461-155-0250; 461-155-0290; 461-160-0540; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

2a. Reduction of OSIPM to QMB benefits due to an increase in countable resources, not potentially MAGI-eligible (SDS 540)

You have resources that exceed the $2000/,$3,000 limit for the Oregon Supplemental Income Program-Medical (OSIPM). The only program you qualify for is the Qualified Medicare Beneficiary program (QMB) that pays your Medicare premiums, some co-pays & deductibles. You are not eligible for the MAGI Medicaid programs because you are not pregnant, and you are over 18 or over 64 with Medicare and are not a parent or caretaker relative of a dependent child living with you.
OAR 410-120-1210; 410-200-0415(2); 410-200-0420(3); 410-200-0425(2); 410-200-0435(4); 461-155-0290; 461-160-0015(3),(4); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-170-0130; 461-180-0085

2b. Reduction of OSIPM to QMB benefits due to an increase in countable resources, potentially MAGI-eligible, client returned 7210 and MAGI was denied (SDS 540)

Do not send notice and reduce medical until after 5503 determines eligibility for MAGI medical. If MAGI is approved, 5503 will take the appropriate case actions and no notice is necessary.

You have resources that exceed the $2000/,$3,000 limit for the Oregon Supplemental Income Program-Medical (OSIPM).  The only program you qualify for is the Qualified Medicare Beneficiary program (QMB) that pays your Medicare premiums, some co-pays & deductibles. You will receive a separate notice regarding your eligibility for other Medicaid programs offered by the Department.

OAR 410-120-1210; 461-155-0290; 461-160-0015(3),(4); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-170-0130; 461-180-0085

2c. Reduction of OSIPM to QMB benefits due to an increase in countable resources, potentially MAGI-eligible, client did not return 7210 (SDS 540)

You have resources that exceed the $2000/,$3,000 limit for the Oregon Supplemental Income Program-Medical (OSIPM).  The only program you qualify for is the Qualified Medicare Beneficiary program (QMB) that pays your Medicare premiums, some co-pays & deductibles. On mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-155-0290; 461-160-0015(3),(4); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-170-0130; 461-180-0085

3a. Reduction of OSIPM to SMB due to increased income or change in income, not potentially MAGI-eligible (SDS 540)

Your current adjusted income places you over income for the Oregon Supplemental Income Program-Medical (OSIPM). The only program you qualify for is the Medicare Savings Program that pays your Medicare Part B premium, the Specified Low Income Medicare Beneficiary(SMB) program. You are not eligible for the MAGI Medicaid programs because you are not pregnant, and you are over 18 or over 64 with Medicare and are not a parent or caretaker relative of a dependent child living with you.
OAR 410-120-1210; 410-200-0415(2); 410-200-0420(3); 410-200-0425(2); 410-200-0435(4); 461-001-0000(3); 461-155-0250; 461-155-0290; 461-155-0295(1); 461-160-0540; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

3b. Reduction of OSIPM to SMF due to increased income or change in income, not potentially MAGI-eligible (SDS 540)

Your current adjusted income places you over income for the Oregon Supplemental Income Program-Medical (OSIPM). The only program you qualify for is the Medicare Savings Program that pays your Medicare Part B premium, the Qualified Individual (SMF) program. You are not eligible for the MAGI Medicaid programs because you are not pregnant, and you are over 18 or over 64 with Medicare and are not a parent or caretaker relative of a dependent child living with you.
OAR 410-120-1210, 410-200-0415(2); 410-200-0420(3); 410-200-0425(2); 410-200-0435(4); 461-001-0000(3); 461-155-0250; 461-155-0290; 461-155-0295(2); 461-160-0540; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

3c. Reduction of OSIPM to SMB due to increased income or change in income, potentially MAGI-eligible, 7210 was returned, and MAGI was denied(SDS 540)

Do not send notice and reduce medical until after 5503 determines eligibility for MAGI medical. If MAGI is approved, 5503 will take the appropriate case actions and no notice is necessary.

Your current adjusted income places you over income for the Oregon Supplemental Income Program-Medical (OSIPM). The only program you qualify for is the Medicare Savings Program that pays your Medicare Part B premium, the Specified Low Income Medicare Beneficiary (SMB) program. You will receive a separate notice regarding your eligibility for other Medicaid programs offered by the Department.

OAR 410-120-1210, 461-001-0000(3); 461-155-0250; 461-155-0290; 461-155-0295(1); 461-160-0540; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

3d. Reduction of OSIPM to SMF due to increased income or change in income, potentially MAGI-eligible, 7210 was returned, and MAGI was denied (SDS 540)

Do not send notice and reduce medical until after 5503 determines eligibility for MAGI medical. If MAGI is approved, 5503 will take the appropriate case actions and no notice is necessary.

Your current adjusted income places you over income for the Oregon Supplemental Income Program-Medical (OSIPM). The only program you qualify for is the Medicare Savings Program that pays your Medicare Part B premium, the Qualified Individual (SMF) program. You will receive a separate notice regarding your eligibility for other Medicaid programs offered by the Department.

OAR 410-120-1210; 461-001-0000(3); 461-155-0250; 461-155-0290; 461-155-0295(2); 461-160-0540; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

3e. Reduction of OSIPM to SMB due to increased income or change in income, potentially MAGI-eligible, and client did not return 7210 (SDS 540)

Your current adjusted income places you over income for the Oregon Supplemental Income Program-Medical (OSIPM). The only program you qualify for is the Medicare Savings Program that pays your Medicare Part B premium, the Specified Low Income Medicare Beneficiary (SMB) program. On mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action. You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-001-0000(3); 461-155-0250; 461-155-0290; 461-155-0295(1); 461-160-0540; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

3f. Reduction of OSIPM to SMF due to increased income or change in income, potentially MAGI-eligible, and client did not return 7210 (SDS 540)

Your current adjusted income places you over income for the Oregon Supplemental Income Program-Medical (OSIPM). The only program you qualify for is the Medicare Savings Program that pays your Medicare Part B premium, the Qualified Individual (SMF) program. On mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action. You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-001-0000(3); 461-155-0250; 461-155-0290; 461-155-0295(2); 461-160-0540; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

4a. Reduction of OSIPM to SMB due to increase in countable resources, not potentially MAGI-eligible (SDS 540)

You have resources that exceed the $2000/,$3,000 limit for the Oregon Supplemental Income Program-Medical (OSIPM). The only program you qualify for is the Medicare Savings Program that pays your Medicare Part B premium, the Specified Low Income Medicare Beneficiary (SMB) program. You are not eligible for the MAGI Medicaid programs because you are not pregnant, and you are over 18 or over 64 with Medicare and are not a parent or caretaker relative of a dependent child living with you.

OAR 410-120-1210; 410-200-0415(2); 410-200-0420(3); 410-200-0425(2); 410-200-0435(4); 461-155-0290; 461-155-0295(1); 461-160-0015(3),(4); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

4b. Reduction of OSIPM to SMF due to increase in countable resources, not potentially MAGI-eligible (SDS 540)

You have resources that exceed the $2000/,$3,000 limit for the Oregon Supplemental Income Program-Medical (OSIPM). The only program you qualify for is the Medicare Savings Program that pays your Medicare Part B premium, the Qualified Individual (SMF) program. You are not eligible for the MAGI Medicaid programs because you are not pregnant, and you are over 18 or over 64 with Medicare and are not a parent or caretaker relative of a dependent child living with you.

OAR 410-120-1210; 410-200-0415(2); 410-200-0420(3); 410-200-0425(2); 410-200-0435(4); 461-155-0290; 461-155-0295(2); 461-160-0015(3),(4); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

4c. Reduction of OSIPM to SMB due to increase in countable resources, potentially MAGI-eligible, 7210 was returned, and MAGI was denied (SDS 540)

Do not send notice and reduce medical until after 5503 determines eligibility for MAGI medical. If MAGI is approved, 5503 will take the appropriate case actions and no notice is necessary.

You have resources that exceed the $2000/,$3,000 limit for the Oregon Supplemental Income Program-Medical (OSIPM). The only program you qualify for is the Medicare Savings Program that pays your Medicare Part B premium, the Specified Limited Medicare Beneficiary (SMB) program. You will receive a separate notice regarding your eligibility for other Medicaid programs offered by the Department.

OAR 410-120-1210; 461-155-0290; 461-155-0295(1); 461-160-0015(3),(4); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

4d. Reduction of OSIPM to SMF due to increase in countable resources, potentially MAGI-eligible, 7210 was returned, and MAGI was denied (SDS 540)

Do not send notice and reduce medical until after 5503 determines eligibility for MAGI medical. If MAGI is approved, 5503 will take the appropriate case actions and no notice is necessary.

You have resources that exceed the $2000/,$3,000 limit for the Oregon Supplemental Income Program-Medical (OSIPM). The only program you qualify for is the Medicare Savings Program that pays your Medicare Part B premium, the Qualified Individual (SMF) program. You will receive a separate notice regarding your eligibility for other Medicaid programs offered by the Department.

OAR 410-120-1210; 461-155-0290; 461-155-0295(2); 461-160-0015(3),(4); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

 

4e. Reduction of OSIPM to SMB due to increase in countable resources, potentially MAGI-eligible, and client did not return 7210 (SDS 540)

You have resources that exceed the $2000/,$3,000 limit for the Oregon Supplemental Income Program-Medical (OSIPM). The only program you qualify for is the Medicare Savings Program that pays your Medicare Part B premium, the Specified Limited Medicare Beneficiary (SMB) program. On mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action. You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-155-0290; 461-155-0295(1); 461-160-0015(3),(4); 461-110-0210; 461-110-0310;461-110-0410; 461-110-0530(2),(4); 461-170-0130; 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

4f. Reduction of OSIPM to SMF due to increase in countable resources, potentially MAGI-eligible, and client did not return 7210 (SDS 540)

You have resources that exceed the $2000/,$3,000 limit for the Oregon Supplemental Income Program-Medical (OSIPM). The only program you qualify for is the Medicare Savings Program that pays your Medicare Part B premium, the Qualified Individual (SMF) program. On mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action. You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210, 461-155-0290, 461-155-0295(2), 461-160-0015(3),(4), 461-110-0210, 461-110-0310, 461-110-0410, 461-110-0530(2),(4); 461-170-0130, 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

5a. Reduction of OSIPM to QMB due to failure to provide verification of resources, potentially MAGI-eligible, and client did not return 7210 (SDS 540)

You are no longer eligible for Oregon Supplemental Income Program Medical (OSIPM) program. We requested verification from you regarding insert resource type.  To date, we have not received this requested verification. Because we have not received this information, you are not eligible for OSIPM. The only program you qualify for is the Qualified Medicare Beneficiary program (QMB) that pays your Medicare premiums, co-pays & deductibles. On mm/dd/yy we requested that you complete and return an application so that you could be evaluated for other Medicaid programs.  We gave you until mm/dd/yy to complete this action. You have not returned the application; therefore, we cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210, 461-105-0020(1),(2); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0190(1); 461-115-0700; 461-115-0610(1),(2); 461-115-0430(1),(2); 461-160-0010(5); 461-160-0015(4)

5b. Reduction of OSIPM to QMB due to failure to provide verification of resources, not potentially MAGI-eligible (SDS 540)

You are no longer eligible for Oregon Supplemental Income Program Medical (OSIPM) program. We requested verification from you regarding insert resource type.  To date, we have not received this requested verification. Because we have not received this information, you are not eligible for OSIPM. The only program you qualify for is the Qualified Medicare Beneficiary program (QMB) that pays your Medicare premiums, co-pays & deductibles. You are not eligible for the MAGI Medicaid programs because you are not pregnant, and you are over 18 or over 64 with Medicare and are not a parent or caretaker relative of a dependent child living with you.

OAR 410-120-1210, 461-105-0020(1),(2); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0190(1); 461-115-0700; 461-115-0610(1),(2); 461-115-0430(1),(2); 461-160-0010(5); 461-160-0015(4)

6a. Reduction of OSIPM to SMB or SMF due to failure to provide verification of resources, potentially MAGI-eligible, and client did not return 7210 (SDS 540)

You are no longer eligible for Oregon Supplemental Income Program Medical (OSIPM) program. We requested verification from you regarding insert resource type.  To date, we have not received this requested verification. Because we have not received this information, you are not eligible for OSIPM. The only program you qualify for is the Medicare Savings Program that pays your Medicare Part B premium, the Specified Limited Medicare Beneficiary (SMB)/Qualifiying Individual (SMF) program. On mm/dd/yy we requested that you complete and return an application so that you could be evaluated for other Medicaid programs.  We gave you until mm/dd/yy to complete this action. You have not returned the application; therefore, we cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210, 461-105-0020(1),(2); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0190(1); 461-115-0700; 461-115-0610(1),(2); 461-115-0430(1),(2); 461-160-0010(5); 461-160-0015(4)

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

6b. Reduction of OSIPM to SMB or SMF ailure to provide verification of resources, not potentially MAGI-eligible(SDS 540)

You are no longer eligible for Oregon Supplemental Income Program Medical (OSIPM) program. We requested verification from you regarding insert resource type.  To date, we have not received this requested verification. Because we have not received this information, you are not eligible for OSIPM. The only program you qualify for is the Medicare Savings Program that pays your Medicare Part B premium, the Specified Limited Medicare Beneficiary (SMB)/Qualifiying Individual (SMF) program. You are not eligible for the MAGI Medicaid programs because you are not pregnant, and you are over 18 or over 64 with Medicare and are not a parent or caretaker relative of a dependent child living with you.

OAR 410-120-1210, 461-105-0020(1),(2); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0190(1); 461-115-0700; 461-115-0610(1),(2); 461-115-0430(1),(2); 461-160-0010(5); 461-160-0015(4)

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

7a. Reduction of QMB-only to SMB due to a change in income or annual income standard change, not potentially MAGI-eligible (SDS 540)

Your current adjusted income places you over income for your current Medicare Savings Program, Qualified Medicare Beneficiary (QMB) which pays your Medicare premiums, deductibles, and some co-payments. The only program you qualify for is the Specified Low Income Medicare Beneficiary (SMB) program that pays your Medicare Part B premium (SMB does not pay co-pays or deductibles). You are not eligible for the MAGI Medicaid programs because you are not pregnant, and you are over 18 or over 64 with Medicare and are not a parent or caretaker relative of a dependent child living with you.

OAR 410-120-1210, 410-200-0415(2), 410-200-0420(3), 410-200-0425(2), 410-200-0435(4), 461-001-0000(3), 461-110-0210, 461-110-0310, 461-110-0410, 461-110-0530(2), 461-155-0290, 461-155-0295(1), 461-160-0540, 461-160-0552, 461-170-0130, 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

7b. Reduction of QMB-only to SMF due to a change in income or annual income standard change, not potentially MAGI-eligible (SDS 540)

Your current adjusted income places you over income for your current Medicare Savings Program, Qualified Medicare Beneficiary (QMB) which pays your Medicare premiums, deductibles, and some co-payments. The only program you qualify for is the Qualified Individual (SMF) program that pays your Medicare Part B premium (SMF does not pay co-pays or deductibles). You are not eligible for the MAGI Medicaid programs because you are not pregnant, and you are over 18 or over 64 with Medicare and are not a parent or caretaker relative of a dependent child living with you.

OAR 410-120-1210, 410-200-0415(2), 410-200-0420(3), 410-200-0425(2), 410-200-0435(4), 461-001-0000(3), 461-110-0210, 461-110-0310, 461-110-0410, 461-110-0530(2), 461-155-0290, 461-155-0295(2), 461-160-0540, 461-160-0552, 461-170-0130, 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

7c. Reduction of QMB-only to SMB due to a change in income or annual income standard change, potentially MAGI-eligible, 7210 was returned, and MAGI was denied(SDS 540)

Do not send notice and reduce medical until after 5503 determines eligibility for MAGI medical. If MAGI is approved, 5503 will take the necessary case actions and no notice is necessary.

Your current adjusted income places you over income for your current Medicare Savings Program, Qualified Medicare Beneficiary (QMB) which pays your Medicare premiums, deductibles, and some co-payments. The only program you qualify for is the Specified Low Income Medicare Beneficiary (SMB) program that pays your Medicare Part B premium (SMB does not pay co-pays or deductibles). You will receive a separate notice regarding your eligibility for other Medicaid programs offered by the Department.

OAR 410-120-1210, 461-001-0000(3), 461-110-0210, 461-110-0310, 461-110-0410, 461-110-0530(2), 461-155-0290, 461-155-0295(1), 461-160-0540, 461-160-0552, 461-170-0130, 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

7d. Reduction of QMB-only to SMF due to a change in income or annual income standard change, potentially MAGI-eligible, 7210 was returned, and MAGI was denied (SDS 540)

Do not send notice and reduce medical until after 5503 determines eligibility for MAGI medical. If MAGI is approved, 5503 will take the necessary case actions and no notice is necessary.

Your current adjusted income places you over income for your current Medicare Savings Program, Qualified Medicare Beneficiary (QMB) which pays your Medicare premiums, deductibles, and some co-payments. The only program you qualify for is the Qualified Individual (SMF) program that pays your Medicare Part B premium (SMF does not pay co-pays or deductibles). You will receive a separate notice regarding your eligibility for other Medicaid programs offered by the Department.

OAR 410-120-1210, 461-001-0000(3), 461-110-0210, 461-110-0310, 461-110-0410, 461-110-0530(2), 461-155-0290, 461-155-0295(2), 461-160-0540, 461-160-0552, 461-170-0130, 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

7e. Reduction of QMB-only to SMB due to a change in income or annual income standard change, potentially MAGI-eligible, client did not return 7210(SDS 540)

 

Your current adjusted income places you over income for the Qualified Medicare Beneficiary (QMB) program which pays your Medicare premiums, deductibles, and some co-payments. The only program you qualify for is the Specified Low Income Medicare Beneficiary (SMB) program that pays your Medicare Part B premium. (SMB does not pay co-pays or deductibles). On mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210, 461-001-0000(3), 461-110-0210, 461-110-0310, 461-110-0410, 461-110-0530(2), 461-155-0290, 461-155-0295(1), 461-160-0540, 461-160-0552, 461-170-0130, 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

 

7f. Reduction of QMB-only to SMF due to a change in income or annual income standard change, potentially MAGI-eligible, client did not return 7210 (SDS 540)

 

Your current adjusted income places you over income for the Qualified Medicare Beneficiary (QMB) program which pays your Medicare premiums, deductibles, and some co-payments. The only program you qualify for is the Qualified Individual (SMF) program that pays your Medicare Part B premium. (SMF does not pay co-pays or deductibles). On mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210, 461-001-0000(3), 461-110-0210, 461-110-0310, 461-110-0410, 461-110-0530(2), 461-155-0290, 461-155-0295(2), 461-160-0540, 461-160-0552, 461-170-0130, 461-180-0085

For informational purposes ONLY:  Because you were receiving Medicaid benefits which supplemented your Medicare, and the Medicaid benefits are ending, you have what is called “Guaranteed Issue” (GI) rights. This means you have 63 days following the date your benefits end to enroll in a Medigap Supplement plan.  Please contact the Senior Health Insurance Benefits Assistance Program (SHIBA) at 1-800-722-4134 for more information.   Oregon Administrative Rule 836-052-0142(2)(a) establishes who is eligible for the Guaranteed Issue rights.

 

8a. Reduction of OSIPM to QMB due to no longer considered DAC eligible, not potentially MAGI-eligible  (SDS 540)

Note: When removing the DAC C/D, make sure incoming code is SUPL or COMP so the case will recalculate.

Adjust language as needed if reducing to SMB or SMF and add GI rights language.

Your medical benefits will be reduced effective mm/dd/yy. You no longer qualify for Oregon Supplemental Income Program-Medical (OSIPM) as a Disabled Adult Child (DAC). In order to qualify for OSIPM as a DAC, you must meet the eligibility requirements for Supplemental Security Income (SSI) other than the fact that you are receiving your Social Security disabled adult child benefit. You now have other income/resources which exceed the allowable adjusted income/resource limit for the SSI program; therefore, you would not qualify for SSI even if you were not receiving your disabled adult child benefit. Without this protected status, you are now over the adjusted income/resource limit for OSIPM. The only program you qualify for is the Qualified Medicare Beneficiary program (QMB) which pays your monthly Medicare premium, some co-payments and deductibles. You are not eligible for the MAGI Medicaid programs because you are not pregnant, and you are over 18 or over 64 with Medicare and are not a parent or caretaker relative of a dependent child living with you.

OAR 410-120-1210; 410-200-0415(2), 410-200-0420(3), 410-200-0425(2), 410-200-0435(4), 461-001-0000(3), 461-135-0830, 461-155-0250, 461-155-0290, 461-160-0015, 461-160-0540; 461-160-0550, 461-160-0551, 461-160-0552, 461-110-0210, 461-110-0310, 461-110-0410, 461-110-0530(2),(4); 461-170-0130, 461-180-0085

8b. Reduction from OSIPM to QMB due to no longer considered DAC eligible, potentially MAGI-eligible, 7210 was returned, and MAGI was denied  (SDS 540)

Note: When removing the DAC C/D, make sure incoming code is SUPL or COMP so the case will recalculate.

Adjust language as needed if reducing to SMB or SMF and add GI rights language.

Do not send notice and reduce medical until after 5503 determines eligibility for MAGI medical. If MAGI is approved, 5503 will take the necessary case actions and no notice is necessary.

Your medical benefits will be reduced effective mm/dd/yy. You no longer qualify for Oregon Supplemental Income Program-Medical (OSIPM) as a Disabled Adult Child (DAC). In order to qualify for OSIPM as a DAC, you must meet the eligibility requirements for Supplemental Security Income (SSI) other than the fact that you are receiving your Social Security disabled adult child benefit. You now have other income/resources which exceed the allowable adjusted income/resource limit for the SSI program; therefore, you would not qualify for SSI even if you were not receiving your disabled adult child benefit. Without this protected status, you are now over the adjusted income/resource limit for OSIPM. The only program you qualify for is the Qualified Medicare Beneficiary program (QMB) which pays your monthly Medicare premium, some co-payments and deductibles. You will receive a separate notice regarding your eligibility for other Medicaid programs offered by the Department.

OAR 410-120-1210; 461-001-0000(3), 461-135-0830, 461-155-0250, 461-155-0290, 461-160-0015, 461-160-0540; 461-160-0550, 461-160-0551, 461-160-0552, 461-110-0210, 461-110-0310, 461-110-0410, 461-110-0530(2),(4); 461-170-0130, 461-180-0085

8c. Reduction from OSIPM to QMB due to no longer considered DAC eligible, potentially MAGI-eligible, and client did not return 7210  (SDS 540)

Note: When removing the DAC C/D, make sure incoming code is SUPL or COMP so the case will recalculate.

Adjust language as needed if reducing to SMB or SMF and add the GI rights langauge.

Your medical benefits will be reduced effective mm/dd/yy. You no longer qualify for Oregon Supplemental Income Program-Medical (OSIPM) as a Disabled Adult Child (DAC). In order to qualify for OSIPM as a DAC, you must meet the eligibility requirements for Supplemental Security Income (SSI) other than the fact that you are receiving your Social Security disabled adult child benefit. You now have other income/resources which exceed the allowable adjusted income/resource limit for the SSI program; therefore, you would not qualify for SSI even if you were not receiving your disabled adult child benefit. Without this protected status, you are now over the adjusted income/resource limit for OSIPM. The only program you qualify for is the Qualified Medicare Beneficiary program (QMB) which pays your monthly Medicare premium, some co-payments and deductibles. On mm/dd/yy we requested that you complete and return an application so that you could be evaluated by the Department for other Medicaid programs.  We gave you until mm/dd/yy to complete this action.  You have not returned the application; therefore, the Department cannot determine your eligibility for other Medicaid programs.

OAR 410-120-1210; 461-001-0000(3), 461-135-0830, 461-155-0250, 461-155-0290, 461-160-0015, 461-160-0540; 461-160-0550, 461-160-0551, 461-160-0552, 461-110-0210, 461-110-0310, 461-110-0410, 461-110-0530(2),(4); 461-170-0130, 461-180-0085

9. Reduction from QMB to SMB due to a change in income or yearly change in income standards - for OSIPM-eligible clients, no MAGI referral needed SDS 540)

Your current adjusted income places you over income for your current Medicare Savings Program, the Qualified Medicare Beneficiary Program (QMB) that pays your Medicare premiums, deductibles, and some co-payments. You are, however, eligible for the Specified Low Income Medicare Beneficiary (SMB) program that will continue paying your Medicare Part B premium. You remain eligible for the Oregon Supplemental Income Program (OSIPM). OAR 410-120-1210, 461-001-0000(3), 461-155-0290, 461-155-0295(1), 461-160-0540, 461-160-0552

10. Reduction from SMF to SBI due to 2017 change to SMF specific requirements, no MAGI referral needed (SDS 540) You will see no change in your benefits. You are no longer eligible for your current Medicare Savings Program, the Qualified Individual Program (SMF) that pays your Medicare Part B premium, because you are eligible for other Medicaid benefits. You are going to continue getting your Medicare Part B premium paid since you continue to be eligible for the Oregon Supplemental Income Program-Medical (OSIPM). OSIPM pays your medical costs that Medicare does not. OAR 410-120-1210, 461-135-0730(4)

11. Reduction from SMF to CBI due to 2017 change to SMF specific requirements, no MAGI referral needed (SDS 540)

*Note - also send the 540M for the new medical deduction

You are no longer eligible for your current Medicare Savings Program, the Qualified Individual Program (SMF) that pays your Medicare Part B premium, because you are eligible for other Medicaid benefits. You continue to be eligible for Oregon Supplemental Income Program-Medical (OSIPM), and will continue to pay a liability or service payment for the long-term-care services you receive. When we stop paying your Medicare Part B premium, the premium will be taken directly out of your Social Security payment. The amount you receive from Social Security will be smaller, but the amount you pay for your services will be reduced by the same amount. In this way you will continue to receive the same total benefit. OAR 410-120-1210, 461-135-0730(4), 461-160-0030, 461-160-0055(3), 461-160-0610, 461-160-0620(3)(g)

12. Reduction from SMB to SBI due to a change in income, no MAGI referral needed (SDS 540) You will see no change in your benefits. Your current adjusted income places you over income for your current Medicare Savings Program, the Specified Low Income Medicare Beneficiary (SMB) program that pays your Medicare Part B premium. You are not eligible for the Qualified Individual Medicare Savings Program (SMF) because you are still eligible for and receiving Medicaid. You are going to continue getting your Medicare Part B premium paid since you continue to be eligible for the Oregon Supplemental Income Program-Medical (OSIPM). OSIPM pays your medical costs that Medicare doesn’t. OAR 410-120-1210, 461-001-0000(3), 461-135-0730(4), 461-155-0295(1), 461-160-0540(4), 461-160-0552

13. Reduction of SMB to CBI due to a change in income or yearly change in income standards, no MAGI referral needed (SDS 540)

*Note - also send the 540M for the new medical deduction

Your current adjusted income places you over income for your current Medicare Savings Program, the Specified Low Income Medicare Beneficiary (SMB) program that pays your Medicare Part B premium. You are not eligible for the Qualified Individual Medicare Savings Program (SMF) because you are still eligible for and receiving Medicaid benefits. You continue to be eligible for Oregon Supplemental Income Program-Medical (OSIPM), and will continue to pay a liability or service payment for the long-term-care services you receive.  When we stop paying your Medicare Part B premium, the premium will be taken directly out of your Social Security payment.  The amount you receive from Social Security will be smaller, but the amount you pay for your services will be reduced by the same amount.  In this way you will continue to receive the same total benefit. OAR 410-120-1210, 461-001-0000(3), 461-135-0730(4), 461-155-0295(1), 461-160-0030, 461-160-0055(3), 461-160-0540(4), 461-160-0552, 461-160-0610, 461-160-0620(3)(g)
14. Change from SBI to CBI due to a change in income, ongoing service client with an existing service liability, no MAGI referral needed (use the SDS 540M)

You will begin receiving a medical deduction effective mm/dd/yyyy because the State of Oregon will no longer pay your Medicare Part B premium.  This happens when someone's service payment is more than the current Part B premium. You continue to be eligible for Oregon Supplemental Income Program-Medical (OSIPM), and will continue to pay a liability or service payment for the long-term-care services you receive. When we stop paying your Medicare Part B premium, the premium will be taken directly out of your Social Security payment. The amount you receive from Social Security will be smaller, but the amount you pay for your services will be reduced by the same amount. In this way, you will continue to receive the same total benefit. OAR 410-120-1210, 461-160-0030, 461-160-0055(3), 461-160-0610, 461-160-0620(3)(g)

15. Change from SBI to CBI due to a change in income, ongoing service client with a first-time service liability, no MAGI referral needed (use the SDS 540M or add to 540P)

You will begin receiving a medical deduction effective mm/dd/yyyy because the State of Oregon will no longer pay your Medicare Part B premium.  You continue to be eligible for Oregon Supplemental Income Program-Medical (OSIPM), and will now be responsible for paying a liability or service payment for the long-term-care services you receive. The state stops paying Medicare part B premiums when someone's service payment is more than the current Part B premium. When we stop paying your Medicare Part B premium, the premium will be taken directly out of your Social Security payment. The amount you receive from Social Security will be smaller, but the amount you pay for your services will be reduced by the same amount. In this way, you will continue to receive the same total benefit. OAR 410-120-1210, 461-160-0030, 461-160-0055(3), 461-160-0610, 461-160-0620(3)(g)

16. Change from SBI to CBI due to a change in income, new service client who was already receiving OSIPM and SBI no MAGI referral needed (add this language to the SDS 541)

The State of Oregon will no longer pay your Medicare Part B premium effective mm/dd/yyyy.  This happens when someone's service payment is more than the the current Part B premium. You continue to be eligible for Oregon Supplemental Income Program-Medical (OSIPM).  You have been approved for the services above and are responsibility to pay a liability or service payment for the long-term-care services you receive. When we stop paying your Medicare Part B premium, the premium will be taken directly out of your Social Security payment. The amount you receive from Social Security will be smaller, but the amount you pay for your services will be reduced by the same amount. In this way, you will continue to receive the same total benefit. OAR 410-120-1210, 461-160-0030, 461-160-0055(3), 461-160-0610, 461-160-0620(3)(g)

17. Reduction from MAGI Medicaid to QMB-BAS

OHA/5503 is responsible for notifying MAGI recipients of closure. An approval notice will be mailed automatically when the case is opened on CMS.

18. Reduction from MAGI Medicaid to SMB or SMF.

OHA/5503 is responsible for notifying MAGI recipients of closure. An approval notice will be mailed automatically when the case is opened on CMS.

19. Reduction of OSIPM due to increased Participant Fee (add this language to the SDS 0850E)

Your monthly participant fee of $amount for the Employed Persons with Disabilities (EPD) program will be increased to $amount effective mm/dd/yy because your income, which the Department uses to calculate your fee, has increased.

OAR 410-120-0006; 461-001-0035; 461-160-0800;461-115-0610(1),(2),(3); 461-115-0700; 461-155-0290; 461-170-0130

20. Reduction of OSIPM due to enrollment into EPD with Participant Fee (add this language to the SDS 0850E)

Your income puts you over the limit for the Oregon Supplemental Income Program Medical (OSIPM) Plus coverage. You are eligible for the Employed Persons with Disabilities (OSIPM-EPD) program. The OSIPM-EPD program gives you OHP Plus coverage, but you are required to pay a participant fee each month in order to receive this benefit.

OAR 461-001-0035;461-115-0610(1),(2),(3); 461-115-0700; 461-155-0290; 461-170-0130

Medical Denial

1. Failure to provide requested verification (SDS 540)

Provide client with date stamped 7210 application form. Instruct the client to complete the application, sign it, and return it to address printed on the 7210 form.

*No 7210 is needed if this was the result of a ONE referral from 5503.  If so, delete the last two sentences.

Your application for the Oregon Supplemental Income Program Medical (OSIPM)/Medicare Savings Programs (QMB/SMB/SMF) is denied. We requested verification from you regarding insert verification type.  To date, we have not received this requested verification. Because we have not received this information, you are not eligible for medical benefits offered by Aging and People with Disabilities. You may be eligible for other medical programs offered by the Department. You were provided with an application and will be contacted regarding your eligibility for their programs.

OAR 410-120-1210, 461-105-0020(1),(2); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0190(1); 461-115-0700; 461-115-0610(1),(2); 461-115-0430(1),(2)

2. Failure to complete interview  (SDS 540)

*No referral to 5503 necessary.

Your application for the Oregon Supplemental Income Program Medical (OSIPM)/Medicare Savings Programs (QMB/SMB/SMF) is denied. On mm/dd/yy we requested that you contact us to schedule an interviewWe gave you until mm/dd/yy to complete this action.  You have not fill in action - contacted us/completed an interview; therefore, we cannot determine your eligibility for Medicaid.

OAR 410-120-1210; 461-105-0020(1),(2),(6), 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0190(1), 461-115-0230(5)

3. Denial of OSIPM for being over income and ineligible for all APD medical programs  (SDS 540)

Provide client with date stamped 7210 application form. Instruct the client to complete the application, sign it, and return it to address printed on the 7210 form.

*No 7210 is needed if this was the result of a ONE referral from 5503.  If so, delete the last two sentences.

You are not eligible for Oregon Supplemental Income Program-Medical (OSIPM) because you are over the income standard. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You may be eligible for other medical programs offered by the Department. You were provided with an application and will be contacted regarding your eligibility for their programs.

OAR 410-120-1210; 461-001-0000(3); 461-155-0250; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

4. Denial of OSIPM for being over income - current QMB-BAS client who was denied services. (SDS 540)

Note: Send separate service denial notice.

You are not eligible for Oregon Supplemental Income Program-Medical (OSIPM) because you are over the income standard. The only program administered by Aging and People with Disabilities that you qualify for is the program you are currently receiving – the Qualified Medicare Beneficiary program (QMB-BAS) that pays your Medicare premiums, some co-pays & deductibles.

OAR 410-120-1210; 461-001-0000(3); 461-155-0250; 461-155-0290; 461-160-0540(1),(2); 461-160-0550, 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

5. Denial of OSIPM for being over income - current SMB/SMF client who was denied services. (SDS 540)

Note: Send separate service denial notice

You are not eligible for Oregon Supplemental Income Program-Medical (OSIPM) because you are over the income standard. The only program administered by Aging and People with Disabilities that you qualify for is the program you are currently receiving – the Specified Low Income Medicare Beneficiary(SMB)/Qualified Individual (SMF) program that will continue paying your Medicare Part B premium.

OAR 410-120-1210, 461-001-0000(3); 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0540(1),(2); 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

6. Denial of QMB programs for being over income and ineligible for all APD medical programs  (SDS 540)

Provide individual with date-stamped 7210 application form with instructions to complete and sign the application and return it to address printed on the 7210 form.

*No 7210 is needed if this was the result of a ONE referral from 5503.  If so, delete the last two sentences

You are not eligible for the Medicare Savings Programs (QMB/SMB/SMF) because you are over the income standard. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You may be eligible for other medical programs offered by the Department. You were provided with an application and will be contacted regarding your eligibility for their programs.

OAR 410-120-1210; 461-155-0290; 461-155-0295; 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

 

7. Denial of OSIPM for being over resources and ineligible for all APD medical programs  (SDS 540)

Provide individual with date-stamped 7210 application form with instructions to complete and sign the application and return it to address printed on the 7210 form.

*No 7210 is needed if this was the result of a ONE referral from 5503.  If so, delete the last two sentences.

You are not eligible for Oregon Supplemental Income Program-Medical (OSIPM) because you have resources that exceed the $2,000/$3,000 limit. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You may be eligible for other medical programs offered by the Department. You were provided with an application and will be contacted regarding your eligibility for their programs.

OAR 410-120-1210; 461-160-0010(3); 461-160-0015(3); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

8. Denial of presumptive OSIPM based on binding SSA decision and is not eligible for any APD medical - individual is receiving MAGI and applied for GA (SDS 540)

You must be determined disabled to qualify for the Oregon Supplemental Income Program-Medical (OSIPM). Social Security Administration (SSA) disability decisions are binding on the state Medicaid agency, even if you are appealing them. SSA decided you are not disabled. To our knowledge, you have no new disabling condition that SSA failed to consider. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits.  In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. This does not change or affect any Medicaid benefits you are receiving from the Department.

OAR 410-120-1210; 461-125-0310; 461-125-0370(1),(2),(3),(4); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0330; 461-125-0350; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

9. Denial of presumptive OSIPM based on binding SSA decision, client was found ineligible for MAGI, was applying for services, EPD, or GA, and is not eligible for any APD medical (SDS 540)

 

You must be determined disabled to qualify for the Oregon Supplemental Income Program-Medical (OSIPM) that provides the Plus benefit package. Social Security Administration (SSA) disability decisions are binding on the state Medicaid agency, even if you are appealing them. SSA decided you are not disabled. To our knowledge, you have no new disabling condition that SSA failed to consider. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You should have received a notice from the Department about your eligibility for Medicaid programs it administers.

OAR 410-120-1210; 461-125-0310; 461-125-0370(1),(2),(3),(4),(5),(6); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0330; 461-125-0350; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

10. Denial of presumptive OSIPM based on binding SSA decision, client has not applied for or is not receiving MAGI, was applying for services or EPD and is not eligible for any APD medical* (SDS 540)

*If possible, provide a date-stamped 7210 or refer individual to a community partner in lieu of having individual complete 539A and completing a PMDDT referral. If a 539A has already been submitted and individual does not wish to withdraw, provide a date-stamped 7210 application form, instruct the individual to complete and sign the application and return it to address printed on the 7210 form, complete the PMDDT referral process and use the language below in the event of a binding SSA decision.

You must be determined disabled to qualify for the Oregon Supplemental Income Program-Medical (OSIPM) that provides the Plus benefit package. Social Security Administration (SSA) disability decisions are binding on the state Medicaid agency, even if you are appealing them. SSA decided you are not disabled. To our knowledge, you have no new disabling condition that SSA failed to consider. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You may be eligible for other medical programs offered by the Department. You were provided with an application and will be contacted regarding your eligibility for its programs.

OAR 410-120-1210; 461-125-0310; 461-125-0370(1),(2),(3),(4),(5),(6); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0330; 461-125-0350; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

11. Denial of OSIPM based on PMDDT decision that individual isn’t disabled and is not eligible for any APD medical - individual is receiving MAGI and applied for GA(SDS 540)

 

You must be determined disabled to qualify for the Oregon Supplemental Income Program-Medical (OSIPM) per the Social Security Administration's (SSA) disability standards. After reviewing the medical and other evidence in your case, the Department has determined that you do not meet SSA's disability standards. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. This does not change or affect any Medicaid benefits you are receiving from the Department.

OAR 410-120-1210; 461-125-0310; 461-125-0370(1),(2),(3),(4),(5),(6); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0330; 461-125-0350; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

12. Denial of OSIPM based on PMDDT decision that individual isn’t disabled, was found ineligible for MAGI, was applying for services or EPD, and is not eligible for any APD medical (SDS 540)

You must be determined disabled to qualify for the Oregon Supplemental Income Program-Medical (OSIPM) per the Social Security Administration's (SSA) disability standards. After reviewing the medical and other evidence in your case, the Department has determined that you do not meet SSA's disability standards. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets Social Security standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You should have received a notice from the Department about your eligibility for Medicaid programs it administers.

OAR 410-120-1210; 461-125-0310; 461-125-0370(1),(2),(3),(4),(5),(6); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0330; 461-125-0350; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

13. Denial of OSIPM due to failure to comply with PMDDT and is not eligible for any APD medical program - individual is receiving MAGI and applied for GA (SDS 540)

Your application for medical benefits under Oregon Supplemental Income Program Medical (OSIPM) is denied because you failed to comply with the eligibility requirements. In order to be eligible for OSIPM, clients must cooperate in obtaining sufficient medical documentation for the Department to determine eligibility. You failed to cooperate in obtaining sufficient medical documentation by failing to attend a medical examination that was scheduled for mm/dd/yy at hh:mm with Dr. _________ and rescheduled for mm/dd/yy at hh:mm. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets the Social Security Administration's standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. This does not change or affect any Medicaid benefits you are receiving from the Department.

OAR 410-120-1210; 461-105-0020(1),(2),(6); 461-125-0310; 461-125-0370(1),(2),(3),(4),(5),(6); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0330; 461-125-0350; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

14. Denial of OSIPM due to failure to comply with PMDDT, was found ineligible for MAGI, was applying for services or EPD, and is not eligible for any APD medical program (SDS 540)

Your application for medical benefits under Oregon Supplemental Income Program Medical (OSIPM) is denied because you failed to comply with the eligibility requirements. In order to be eligible for OSIPM, clients must cooperate in obtaining sufficient medical documentation for the Department to determine eligibility. You failed to cooperate in obtaining sufficient medical documentation by failing to attend a medical examination that was scheduled for mm/dd/yy at hh:mm with Dr. _________ and rescheduled for mm/dd/yy at hh:mm. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets the Social Security Administration's standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You should have received a notice from the Department about your eligibility for Medicaid programs it administers.

OAR 410-120-1210; 461-105-0020(1),(2),(6); 461-125-0310; 461-125-0370(1),(2),(3),(4),(5),(6); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0330(1),(3); 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0330; 461-125-0350; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

15. Denial of presumptive OSIPM due to failure to comply with pursuit of SSDI, has been found ineligible for MAGI, was applying for services or EPD, and is not eligible for any APD medical (SDS 540)

 

We requested that you follow through on your application for Social Security benefits from the Social Security Administration. We have not received proof that you have done that. Because we have not received this information, your application for medical assistance has been denied. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets the Social Security Administration's standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. You should have received a notice from the Department about your eligibility for Medicaid programs it administers.

OAR 410-120-1210; 461-105-0020(1),(2),(6); 461-120-0330(1),(3); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

16. Denial of presumptive OSIPM due to failure to comply with pursuit of SSDI and is not eligible for any APD medical - individual is receiving MAGI and applied for GA (SDS 540)

 

We requested that you follow through on your application for Social Security benefits from the Social Security Administration. We have not received proof that you have done that. Because we have not received this information, your application for medical assistance has been denied. You do not qualify for any medical assistance programs administered by Aging and People with Disabilities (APD). To be eligible for Oregon Supplemental Income Program Medical (OSIPM), you must be age 65 or older, blind, or have a disability that meets the Social Security Administration's standards AND have assumed or protected eligibility or be within the income and resource limits. In order to qualify for the Medicare Savings Programs (QMB, SMB, SMF), you must have Medicare Part A and have income within the allowable program limits. You must also meet all other non-financial eligibility requirements and complete the application and verification process to qualify for APD medical programs. This does not change or affect any Medicaid benefits you are receiving from the Department.

OAR 410-120-1210; 461-105-0020(1),(2),(6); 461-120-0330(1),(3); 461-110-0210; 461-110-0310; 461-110-0410; 461-110-0530(2),(4); 461-115-0010(1),(2),(3); 461-115-0020; 461-115-0230(5); 461-115-0540; 461-115-0610(1),(2),(3); 461-115-0700; 461-120-0315; 461-120-0345; 461-120-0510(1),(4),(5),(6),(7); 461-125-0310; 461-125-0330; 461-125-0350; 461-125-0370; 461-135-0730; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0780; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830; 461-155-0250; 461-155-0290; 461-155-0295; 461-160-0010(3),(4),(5); 461-160-0015(3),(4),(5); 461-160-0540; 461-160-0550; 461-160-0551; 461-160-0552; 461-170-0130; 461-180-0085

Miscellaneous

1. Inmate of an institution - no MAGI referral needed (SDS 540)

To receive medical benefits you cannot be an inmate of a public institution. You are currently considered an inmate of a public institution. You are not eligible for any other Medicaid program. OAR 410-120-1210; 410-200-0140(1); 461-135-0950(1),(2),(3),(4),(5),(6),(7)
2. Disqualifying transfer of resources (SDS 540) Send the SDS 0540T for services and an SDS 540 for medical if the applicant is ineligible for all medical programs. Use notice language appropriate for the applicant’s scenario (e.g. over income). Otherwise approve for appropriate program.  Send SDS 0544 if appropriate (see the OSIP WG-7)

3. Voluntary Withdrawal Basic decision notice - non continuing benefits (SDS 540)

Note: This notice is not needed for a denial if the client signs and submits a 457D.

You have withdrawn your application for benefits. You may reapply at any time. OAR 410-120-1210, 461-115-0010(6),(7), 461-175-0340(1)

SNAP Closure

1. Client is over income You are no longer eligible for SNAP benefits because your new/change in income puts you over the allowable income limit.  OAR 461-155-0190, 461-160-0400, 461-150-0070, 461-160-0430, 461-160-0420, 461-160-0060, 461-180-0030; 461-135-0505
2. Client is a resident of an institution

You were admitted to an institution on mm/dd/yy. Residents of institutions are not eligible for food benefits. OAR 461-135-0510

3. Client moved into AFH You now reside in an adult foster home. Residents of adult foster homes licensed by the state must apply with their caregiver to be eligible for food benefits. Since your caregiver is not applying for food benefits, you are not eligible for this benefit. OAR 461-110-0370, 461-135-0530.
4. Client is a fleeing felon You are not eligible for food benefits because you are considered to be a fleeing felon; in violation of parole; in violation of probation; or in violation of post-prison supervision. OAR 461-110-0310, 461-110-0630, 461-135-0560 
5. Failure to provide requested info To be eligible for food benefits, you are required to provide information when requested by the Department.  We requested information from you about specific info requested on 539H. You have not provided that verification. OAR 461-105-0020, 461-115-0610, 461-115-0651
6. Benefits end at Recert Basic decision notice - non continuing benefits

Your food benefits are ending because you did not return your application, complete the intake, over income, etc. Rules will vary based on reason. OAR 461-115-0450

7. Cannot remain in own filing group (not AFH) You have had a change in your household composition. You now reside with __________ and buy and prepare your food together. Individuals in the same household who purchase and prepare meals together, must apply together to be eligible for food benefits. Since ___________ has applied for and receives food benefits, you will be added to his/her food benefit case. You are no longer eligible for a separate food benefit case. Your food benefit case will close effective mm/dd/yy. OAR 461-110-0370, 461-110-0210, 461-110-0310, 461-110-0530, 461-110-0750, 461-180-0010

SNAP Reduction

1. Receipt of new income CASE NOT IN SRS

You have new/a change in income that must be used when calculating your food benefits. Adding this income to your case caused your food benefits to be reduced. OAR 461-155-0190, 461-160-0400, 461-150-0070, 461-160-0430, 461-160-0420, 461-160-0060, 461-180-0030

2. Change in shelter  expense CASE NOT IN SRS

You have had a change in your shelter amount. This change resulted in a decrease in your food benefits. Since your shelter cost went down, your food benefits went down. OAR 461-160-0420, 461-160-0060, 461-155-0190, 461-160-0400, 461-160-0430, 461-180-0030

3. Change in medical deductions CASE is in SRS You have had a change in your medical costs. This change resulted in a decrease in your food benefits. Since your medical cost went down, your food benefits went down. OAR 461-160-0055, 461-160-0060, 461-160-0400, 461-160-0415, 461-160-0430, 461-180-0030

4. Change in income CASE is in SRS

You have new/a change in income that must be considered in calculating your food benefits. Adding this income to your case caused your food benefits to go down. OAR 461-170-0011, 461-180-0006, 461-155-0190, 461-160-0400, 461-150-0070, 461-160-0430, 461-160-0420, 461-160-0060, 461-180-0030

5. Change in shelter expense CASE is in SRS

You have had a change in your shelter amount. This change resulted in a decrease in your food benefits.  When your shelter costs change, it changes your food benefits. Since your shelter costs went down, your food benefits went down. OAR 461-160-0420, 461-160-0060, 461-155-0190, 461-160-0400, 461-160-0430, 461-180-0030, 461-170-0020, 461-180-0006

6.Change in household composition

You have had a change in your household composition. The number of people in your household affects the amount of benefits you receive. Due to this change, your food benefits went down. OAR 461-110-0210, 461-110-0310, 461-110-0530, 461-110-0750

SNAP Denial

1. Receipt of Foods from California

Your application for food benefits for mm/yy is denied because you are receiving the California State Supplement with your Supplemental Security Income (SSI) benefits.  The SSI benefits issued from California include money for you to use to purchase food.  Because you are receiving the California State Supplement in mm/yy as verified with Social Security, we cannot approve your food benefits in Oregon for this same period of time.  You cannot get the same benefits from two different states for the same time period. OAR 461-165-0030, 461-110-0370

2. Client does not meet citizenship/alien status requirements

To receive food benefits, you must be a U.S. Citizen or meet the requirements of a qualified non-citizen. You entered the United States on mm/yy. You are not considered a refugee or here under asylum. You do not meet any of the other special INS criteria for U.S. residency. You have not worked 40 qualifying quarters while residing in the U.S.. You are not on active duty or a veteran of the US armed forces. You have not lawfully resided in the US for 5 years.  You do not qualify for food benefits. OAR 461-120-0110, 461-120-0125

3. Failure to provide requested info To be eligible for food benefits, you are required to provide information when requested by the Department.  We requested information from you about specific info requested on 539H. You have not provided that verification. OAR 461-105-0020, 461-115-0610, 461-115-0651
4. Client is a fleeing felon You are not eligible for food benefits because you are considered to be a fleeing felon; in violation of parole; in violation of probation; or in violation of post-prison supervision. OAR 461-110-0310, 461-110-0630, 461-135-0560 
5. Medical deduction denial
(choose one)
  • Your request for a medical deduction for food benefits is being denied as you do not meet the food benefit definition of elderly or disabled. OAR 461-001-0015

  • Your request for a medical deduction for food benefits is being denied as the reported expense is in the last month of your certification period.  Since the bill is already paid there is no adjustment to your food benefits. OAR 461-001-0000, 461-115-0450, 461-160-0415, 461-180-0020

  • Your request for a medical deduction for food benefits is being denied as the reported medical expense was paid in full in a prior certification period and you cannot claim the same bill twice. OAR 461-001-0000, 461-160-0030, 461-160-0415

  • Your request for a medical deduction for food benefits is being denied as the reported medical expense is past due and you do not have an installment plan or the installment plan was defaulted on.  OAR 461-160-0415

  • Your request for a medical deduction for food benefits is being denied as the reported medical expense is being paid by someone outside the food benefits filing group and cannot be claimed as an expense by you. OAR 461-160-0030

  • Your request for a medical deduction for food benefits is being denied as the reported medical expense is not prescribed or provided by a medical practitioner.  OAR 461-160-0055

  • Your request for a medical deduction for food benefits is being denied as the reported medical expense is for a person who is no longer in your household group. OAR 461-110-0210, 461-110-0370,  461-160-0415, 461-160-0030

  • Your request for a medical deduction for food benefits is being denied. You are required to provide information when requested by the Department. We requested information from you about specific medical verification/info requested on 539H. You have not provided that verification. OAR 461-001-0015, 461-105-0020, 461-115-0610, 461-115-0651, 461-160-0055

Service Issues

Service Closure - This entire section has been updated as of 4/1/19

Situation

540 reason should include:

1. Not OSIPM or MAGI eligible

Use SDS 540, not SPAN

Note: If the OSIPM eligibility is based on receipt of services and client is not MAGI eligible, send a separate 540 to close/reduce medical.

To be eligible for long-term care services or State Plan Personal Care, you must be eligible for either Oregon Supplemental Income Program-Medical (OSIPM) or a Modified Adjusted Gross Income (MAGI) Medicaid program (also known as Medicaid OHP Plus benefit). You are not eligible for these programs and will receive a separate notice regarding that decision. Because you are not eligible for OSIPM or MAGI, you are not eligible to receive Medicaid funded long-term care services.

Oregon Administrative Rules 411-015-0015(1)(a); 411-015-0100(1)(b)(A)(c); 411-034-0030(1)(b); 410-200-0435.; 461-001-0030; 461-101-0010(16); 461-135-0010; 461-135-0745; 461-135-0750; 461-135-0771; 461-135-0790; 461-135-0800; 461-135-0820; 461-135-0830. 

2. Failure to employ an enrolled HCW or contracted in-home care agency within 14 business days

Note: Individuals may receive case management services as described in OAR 411-028 if they are not MAGI eligible.

This is no longer a valid reason to close services.  Please review APD-PT-18-023.

 

3. Individual does not make a pay-in for services 

Use SDS 540, not SPAN

Note: If the OSIPM eligibility is based on receipt of services, send a separate 540 to close/reduce medical.

The auto-generated "Services Termination Notice" serves as a timely continuing benefit notice. No 540 for services needed.

4. Individual no longer meets the SPL and is not eligible for EWE or SPPC

Note: If the OSIPM eligibility is based on receipt of services and the individual is not MAGI eligible, send a separate 540 to close/reduce medical.

SPAN (SDS 2780N) should be utilized to close services, deny SPPC and deny EWE. See APD-PT-18-031, APD-PT-18-042, APD-PT-18-048.

5. Not eligible as service needs related to mental or emotional disorder (MH)

Use SDS 540, not SPAN

Note: If the OSIPM eligibility is based on receipt of services and the individual is not MAGI eligible, send a separate 540 to close/reduce medical.

The MED team will include the specific language to use in the decision notice.

Oregon Administrative Rules 411-015-0005 (29) and (38), 411-015-0008(1), 411-015-0015 (2) and (5), 411-034-0010; 411-034-0030; 411-034-0035.

 

6. Not eligible for services due to natural supports

Note: If the OSIPM eligibility is based on receipt of services, send a separate 540 to close/reduce medical.

This is no longer a valid reason to close services

Please review APD-PT-18-023

7. Not eligible for SPPC - no need for Personal Care Services

You are not eligible for State Plan Personal Care Services (SPPC) because you do not require assistance from another person with one or more personal care services including:  basic personal hygiene, toileting, bowel and bladder care, nutrition, mobility, transfers or repositioning, medication and oxygen management, or delegated nursing tasks as described in OAR 411-034-0020. The reason you are not eligible for SPPC is based upon your identified care needs and a summary is attached as a part of this notice. (copy synopsis summary from the SPPC assessment)

Oregon Administrative Rules 411-034-0010(4)(5)(6)(14)(34)(42)(44)(c)(46); 411-034-0020(1)(a), (2)(a-f)(3)(a-e); 411-034-0030(1)(a)(b); 411-034-0070(1)(a)(b)(c); 411-034-0090(1)

8. Not eligible for SPPC due to Natural Supports

Individuals receiving SPPC services are not eligible for waivered case management services.

Use SDS 540, not SPAN

You are not eligible for State Plan Personal Care Services because your natural support system (family, friends, neighbors or community resources) is meeting all your assessed service needs. The Department can only authorize payment when the natural support system is unavailable, insufficient or inadequate to meet your service needs. This decision is based on the information gathered during your assessment and interview with you on mm/dd/yy. The Department has reviewed your eligibility and you do not qualify for the Medicaid long-term care service program.

Oregon Administrative Rules 411-015-0005(4)(30); 411-015-0006; 411-015-0007; 411-015-0008(1)(a)(C)(c)(2)(a)(b)(A-D)(d); 411-015-0015(6); 411-027-0005(13)(22); 411-027-0020(1)(a)(b)(2)(a)(b); 411-034-0010(5)(6)(14)and(30); 411-034-0020(1)(a)(b); 411-034-0030(1)(2)(c); 411-034-0070(1)(a)(C)(b)(A)

9. Not eligible for SPPC - without a provider for 30 or more days

Use SDS 540, not SPAN

You are not eligible for State Plan Personal Care Services because you have failed to receive personal care from a qualified provider paid by the Department for 30 continuous calendar days or longer.

Oregon Administrative Rules 411-034-0010(36); 411-034-0020(1))a-d)(2)(a-f)(3)(a-e); 411-034-0030(1)(a)(b)(2)(a-d)(3)(5)(6)(a)(b); 411-015-0015(1)(a-c)(2)(a)(b)

10. Determined eligible by Developmental Disability Program

Use SDS 540, not SPAN

Note: If the OSIPM eligibility is based on receipt of services and the individual is not MAGI eligible, send a separate 540 to close/reduce medical.

Persons under age 65 who are determined eligible for developmental disability services are not eligible for Aging and People with Disabilities (APD) services under the K-State Plan. You were determined eligible by Developmental Disabilities Services on mm/dd/yy, therefore, you are not eligible for Home and Community Based Services. The Department has reviewed your eligibility and you do not qualify for any of the APD funded Medicaid long-term care service programs.

Oregon Administrative Rules 411-015-0005(27); 411-015-0015(1)(a-c)(2)(a)(b)(3)(4)(5)(a-c); 411-320-0080(3)(a)(A-D)(b)(A-C)(c)(d)(A-J)(e)(A-C)(8)(10)(11)(a-e)(12)(13)(15)(19)(20); 411-320-0080(1)(a)(A-B)(i-vii)(C)(D)(3)(a)(A-E)(b)(c)(4)(a)(A-B)(b)(c);

11. Failure to participate in annual service assessment

Use SDS 540, not SPAN

Note: If the OSIPM eligibility is based on receipt of services and the individual is not MAGI eligible, send a separate 540 to close/reduce medical.

On mm/dd/yy, we informed you that we needed to reassess your service eligibility as part of your annual review. We have made attempts to schedule this assessment with you on enter in the specific attempts that have been made, include dates and how the attempt was made however, you have failed to cooperate with these efforts. We have been unable to meet with you to complete your assessment for continued service eligibility, therefore, your services are closed effective mm/dd/yy.

Oregon Administrative Rules 411-015-0008(1)(a)(A-C)(b)(c)(d)(A-B)(e)(f)(g)(A-B)(h)(i)(j)(A-B), 461-115-0010; 461-115-0020; 461-115-0190; 461-115-0450; 461-135-0726; 461-135-0750; 461-180-0085

12. Failed to provide information for service assessment

Use SDS 540, not SPAN

Note: If the OSIPM eligibility is based on receipt of services and the individual is not MAGI eligible, send a separate 540 to close/reduce medical.

On mm/dd/yy, we requested specify the information requested. This information was due on mm/dd/yy. To date, we have not received the requested information. Because of your failure to cooperate, your services are closed effective mm/dd/yy.

Oregon Administrative Rules 411-015-0008(1)(a)(A-C)(b)(c)(d)(A-B)(e)(f)(g)(A-B)(h)(i)(j)(A-B); 461-115-0010; 461-115-0020; 461-115-0190; 461-115-0450; 461-115-0610; 461-115-0700; 461-135-0726; 461-135-0750; 461-180-0085

13. MAGI consumer Left a CBC or NF care setting and the consumer is not receiving other services.

 

Effective mm/dd/yy, you are no longer eligible for long-term care services because you have left the choose: assisted living facility, residential care facility, adult foster home, or nursing facility where you were receiving care services. Currently, you are not receiving other services and individuals receiving MAGI medical benefits are not eligible to receive case management services as described in OAR 411-028.

Oregon Administrative Rules 411-015-0100; 411-028-0030; 411-027-0020(1)(2); 411-027-0020(8)(a); 411-027-0025(1)(2); 411-070-0010

14. Closure of Spousal Pay Program due to natural supports

Use SDS 540, not SPAN

This is no longer a valid reason to close services.

Please review APD-PT-18-023 and Oregon Administrative Rules 411-030-0080

An individual may be eligible to receive services in the following ways:

  • In-home services with an HCW
  • In-home services with an IHCA
  • CBC placement
  • Medicaid Home Delivered Meals
  • Adult Day Services
  • Waivered Case Management (direct and indirect contacts; this service regardless of any other service being received must be provided to any consumer that has OSIPM eligibility)
  • K Ancillary Services
  • Specialized Living Services

15. No longer an Oregon resident

Use SDS 540, not SPAN

Send a separate notice for ending medical benefits.

To receive services from the State of Oregon, you must be living in Oregon. According to the information we received, you no longer reside in Oregon. Your services are closed effective mm/dd/yy.

Oregon Administrative Rules 461-120-0010

16. Unable to manage Consumer-Employer duties. Staff issue with Central Office for appropriate language.
17. Unable to safely deliver services Staff issue with Central Office for appropriate language.
18. Close in-home services with a HCW due to credible allegations of fraud.

Staff issue with Central Office for appropriate language.

Oregon Administrative Rule 411-030-0040(1); 411-030-0040(2)(a-c); 411-030-0040(a)(A-G); 411-030-0040(b)(A-B); 411-030-0040(4)(e-f)

19. Close services due to non participation of Waivered Case Management Service contacts.

For you to be eligible for Long-Term Services and Supports, you must be eligible for Oregon Supplemental Income Program-Medical (OSIPM) Medicaid program (also known as Medicaid OHP Plus benefit). Long-Term Services and Supports are the services that pay for your (CM to choose in-home care, Adult Foster Home, Assisted Living, etc.). In order to remain eligible for Long-Term Services and Supports, you must comply with the eligibility requirements of the program. This means you must participate in regular contact with your case manager. We call these contacts Waivered Case Management Services. To meet your eligibility requirements, you and your case manager must talk or see each other at least every (CM to choose month or quarter). The purpose of Waivered Case Management Services is to ensure your ongoing health, safety and well-being. This is a chance for you to address any concerns about your service plan with your case manager. The department has made multiple attempts to contact you, as well as sent you a letter about the need to provide this service. However, since you have chosen to not participate in Waivered Case Management Services, the department must close your Long-Term Services and Supports.

Oregon Administrative Rules 461-105-0020(1) thru (7); 411-028-0030(1) thru (3); and 411-028-0050(1) and (2).

Oregon Administrative Rules that guide this service are: 411-028-0020(1)(a) thru (h) and 411-028-0020(2)(a) thru (h).

20. PACE cases only
Client does not make a pay-in payment for services.  (SDS 540, not SPAN) 

Note: If the medical eligibility is based on receipt of services, send a separate 540 to close/reduce medical (OSIPM) benefits.

In order to be eligible for long-term care services, individuals who have countable income above the Medicaid standard of $______ must pay the difference between their adjusted income and the Medicaid standard. Your pay-in amount is $____. Since you have not made a payment for services for the month of ______, services will close effective _______. You will receive a separate notice regarding PACE enrollment. OAR 461-001-0030; 461-160-0610; 461-160-0620; 461-185-0050; 461-180-0040; 411-015-0015(7); 411-027-0020(1)(2)(c)

Service Denial

1. Not OSIPM or MAGI eligible

Use SDS 540, not SPAN

Note: If the OSIPM eligibility is based on receipt of services and the individual is not MAGI eligible, send a separate 540 to deny medical.

To be eligible for long-term care services or State Plan Personal Care, you must be eligible for either Oregon Supplemental Income Program-Medical (OSIPM) or a Modified Adjusted Gross Income (MAGI) Medicaid program (also known as Medicaid OHP Plus benefit). You are not eligible for these programs and will receive a separate notice regarding that decision. Because you are not eligible for OSIPM or MAGI, you are not eligible to receive Medicaid funded long-term care services.

Oregon Administrative Rules 411-015-0015(1)(a); 411-015-0100(1)(b); 411-034-0030(1)(b)

2. Failure to employ an enrolled HCW

Note: consumers may receive case management services as described in OAR 411-028 if they are not MAGI eligible

This is not a valid reason to deny services.

Please review APD-PT-18-023.

3. Individual does not meet SPL requirements, not eligible for SPPC

Note: If the OSIPM eligibility is based on receipt of services and the consumer is not MAGI eligible, send a separate 540 to deny medical.

SPAN (SDS 2780N) should be used to deny services and to make an eligibility determination for SPPC services.

See APD-PT-18-031, APD-PT-18-042, APD-PT-18-048

The EWE program does not apply.

4. Individual does not meet SPL requirements, eligible for SPPC

Note: Individual must be eligible for and receiving OSIPM or MAGI in the absence of services to be eligible for SPPC

SPAN (SDS 2780N) should be used to deny services and to approve SPPC.

See APD-PT-18-031, APD-PT-18-042, APD-PT-18-048

5. Service needs related to mental or emotional disorder (MH)

Use SDS 540, not SPAN

Note: If the OSIPM eligibility is based on receipt of services and the individual is not MAGI eligible, send a separate 540 to deny medical.

The MED team will include the specific language to use in the decision notice.

Oregon Administrative Rules 411-015-0005 (29) and (38), 411-015-0008(1), 411-015-0015 (2) and (5), 411-034-0010; 411-034-0030; 411-034-0035

6. Not eligible for services due to natural supports

Note: consumers may receive case management services as described in OAR 411-028 if they are not MAGI eligible

This is no longer a valid reason to deny services.

Please review APD-PT-18-023

7. Not eligible for SPPC - does not need assistance in Personal Care Services

SPAN (SDS 2780N) should be used to deny services and SPPC.

8. Not eligible for SPPC due to Natural Supports

SPAN (SDS 2780N) should be used to deny services and SPPC.

9. Determined eligible by Developmental Disability Program

Use SDS 540, not SPAN

Note: If the OSIPM eligibility is based on receipt of services and the individual is not MAGI eligible, send a separate 540 to deny medical.

Persons under age 65 who are determined eligible for developmental disability services are not eligible for Aging and Disability (APD) services under the K-State Plan. You were determined eligible by developmental disabilities services on mm/dd/yy. Therefore, you are not eligible for APD home and community-based services.

Oregon Administrative Rules 411-015-0015(2) through 411-015-0015(4), 411-320-0080, 411-034-0035(2)

10. Exception Hours Denial for in-home services

Use SDS 540 for SPPC hourly exception denials

SPAN (SDS 2780N) should be utilized for in-home service hours denials or partial denials. Specific reasons for the denials should be noted on the form.

See APD-PT-18-031, APD-PT-18-042, APD-PT-18-046

SPPC Denial: The maximum number of hours in a service period is described in OAR 411-034-0090 (1)(a). You have requested an additional XX exception hours. Central Office has determined that, based upon your care needs, you need an additional XX exception hours.

Oregon Administrative Rule (OAR) 411-034-0020(1)(c) and OAR 411-034-0091 (1)(a); per OAR 411-034-0020(1)(d) and OAR 411-034-0090(1)(c); OAR 411-034-0020(1)(d) and OAR 411-034-0090(1)(c); OAR: 411-034-0010(43)

11. Spousal Pay denial due to ineligibility for spousal pay program

Copy appropriate language into SPAN

Note: If the OSIPM eligibility is based on receipt of services and the individual is not MAGI eligible, send a separate 540 to deny medical.

If you are denying for a different reason, please insert appropriate reason, along with OARs, or consult with Central Office.

  1. You have applied for the Spousal Pay Program. You do not require full assistance in four of the six activities of daily living (Mobility, Eating, Cognition, Dressing/Grooming, Elimination, and Bathing/Hygiene). Therefore, you are not eligible for this program.

Oregon Administrative Rules 411-015-0005(2); 411-015-0006; 411-015-0100(2); 411-030-0020(53); 411-030-0080(2)

  1. You have applied for the Spousal Pay Program. You are not eligible for this program because:
    • You are not assessed as a full assist in Mobility, Elimination, or Cognition; and
    • You do not have a debilitating medical condition, a spinal cord injury or similar disability with permanent impairment; or
    • An acute care or hospice need that is expected to last no more than six months.

Oregon Administrative Rules 411-015-0005(2); 411-015-0006; 411-015-0100(2); 411-030-0020(53); 411-030-0080(2)

12. Does not meet in-home service living arrangement rule

Use SDS 540, not SPAN

Note: the individual may still receive case management services as described in OAR 411-028 if they are not MAGI eligible

You are currently eligible for Medicaid-funded in-home support services. However, you may not currently receive these services you do not meet the In-home services living arrangements criteria since you are living in a pick one:  provider-owned or provider rented dwelling that is not your family home and your name is not on the property deed, mortgage, title to the property, or property manager's rental agreement.

Oregon Administrative Rules 411-050-0605(1), 411-030-0020(28)(c), 411-030-0020(37), 411-030-0020(47), 411-030-0033(1) through (3)

13. Failure to participate in service assessment

Use SDS 540, not SPAN

Note: If the OSIPM eligibility is based on receipt of services and the individual is not MAGI eligible, send a separate 540 to deny medical.

On mm/dd/yy we requested that you participate in an assessment and have made attempts to schedule this assessment with you on enter in the specific attempts that have been made, include dates and how the attempt was made and you have not cooperated with these efforts. Because we have been unable to meet with you to complete your assessment, your request for services is denied.

Oregon Administrative Rules 411-015-0008(1)(j)(A), 461-115-0020, 461-180-0085, 461-115-0190(1)

14. Failed to provide information for service assessment

Use SDS 540, not SPAN

Note: If the OSIPM eligibility is based on receipt of services and the individual is not MAGI eligible, send a separate 540 to deny medical.

On mm/dd/yy, we requested specify the information being requested. This information was due on mm/dd/yy. To date, we have not received the requested information. Because of your failure to cooperate, your request for Medicaid services is denied.

Oregon Administrative Rules: 411-015-0008(1)(j)(A), 461-115-0020, 461-115-0190(1), 461-180-0085, 410-200-0110

15. ICP - Does not meet criteria

Use SDS 540, not SPAN

Note: If the OSIPM eligibility is based on receipt of services, send a separate 540 to deny medical.

To be eligible for the Independent Choices Program (ICP), you must be able to manage all the requirements in Oregon Administrative Rules including:

  • Meet all requirements for in-home services;
  • Develop a service plan and budget to meet the needs identified in your CA/PS assessment;
  • Sign and adhere to the ICP participation agreement;
  • Have or be able to establish a checking account for the ICP funds;
  • Provide evidence of a stable living situation for the past three months;
  • Demonstrate the ability to manage money as evidenced by timely and current utility and housing payments;
  • Ensure that your care providers are not subject to abuse or harassment.

You currently are unable to insert all denial reason(s) here. Therefore, you are not eligible to participate in ICP.

You may receive services by a Homecare Worker and/or In-Home Care Agency or a Licensed Care Setting.

Oregon Administrative Rules 411-030-0020(32) through (34); 411-030-0040(3); 411-030-0100(4)(a) and (5)(b)

16. ICP - Inability to manage own finances

 

To be eligible for the Independent Choices Program, you must be able to direct and purchase your own in-home services. You must be able to manage a cash payment, taxes, and payroll responsibility or have a representative that can manage these finances for you or arrange and purchase the ongoing services of a fiscal intermediary, such as an accountant, bookkeeper, or equivalent financial services. You currently do not have a representative and you are unable to insert reason here.

You may receive services by a Homecare Worker and/or In-Home Care Agency or a Licensed Care Setting.

Oregon Administrative Rules 411-030-0020(32) through (34); OAR 411-030-0100(4)(a) through (c) and (5), (5)(b)

Service Reduction

1. Reduction of service hours due to a household of 2 or more consumers receiving services

Use SDS 540, not SPAN if the hours are being reduced outside of an assessment. Otherwise, use SPAN.

See APD-PT-18-031, APD-PT-18-042, APD-PT-18-048

Your hours of service have been reduced because you live in a household where more than one individual is receiving Medicaid funded long-term care services. Activities of Daily Living (ADL) are assessed separately for individuals receiving services in the same household. When two or more individuals living in the same household is eligible for Instrumental Activities of Daily Living (IADL) task hours, the assessed need in Medication Management and Transportation must be authorized for each individual. A payment is made for the individual with the highest number of hours in housekeeping and laundry, meal preparation, and shopping. Two additional IADL hours are allotted per service period for each additional individual to allow for the specific IADL needs of the other individuals receiving services in the household.

Oregon Administrative Rules 411-030-0070(2)(a-e); 411-030-0070(3)(a-e); 411-030-0070(4)

2. Reduction of service hours

SPAN (SDS 2780N) should be used.

See APD-PT-18-031, APD-PT-18-042, APD-PT-18-048

3. Reduction of service hours due to being eligible for Extended Waiver Eligibility (EWE)

SPAN (SDS 2780N) should be used.

See APD-PT-18-031, APD-PT-18-042, APD-PT-18-048

NOTE: Send the form “Notice of Eligibility and Responsibility” (form 541) to inform consumers of their approved hours for EWE, in conjunction with SPAN.

4. Reduction from waivered or K Plan services to State Plan Personal Care

SPAN (SDS 2780N) should be used.

See APD-PT-18-031, APD-PT-18-042, APD-PT-18-048

5. Reduction in SPPC hours due to reduced personal care needs

Use SDS 540, not SPAN

Note: Individual must be eligible for and receiving OSIPM or MAGI in the absence of services to be eligible for SPPC.

An assessment and interview were conducted in your residence on mm/dd/yy. The authorized hours for State Plan Personal Care Services will be reduced from xx hours to xx hours per service period because your ability to meet your needs in insert ADL(s) has improved.

Oregon Administrative Rules 411-034-0000, 411-034-0010(14), 411-034-0020(1)(a-d), 411-034-0070(1)(a-d), 411-034-0090(1)

6. Reduction in SPPC hours due to natural supports

Use SDS 540, not SPAN

Note: Individual must be eligible for and receiving OSIPM or MAGI in the absence of services to be eligible for SPPC.

Effective mm/dd/yy, your State Plan Personal Care hours are being reduced from xx hours to xx hours per service period because your natural support system (i.e., family, friends, neighbors, or community resources) is helping with the following needs: insert activities. The Department can only authorize payment when natural supports are unavailable, insufficient or inadequate to meet your care needs. This decision is based on the information gathered during the assessment and interview with you on mm/dd/yy.

Oregon Administrative Rules 411-034-0000, 411-034-0010(14), 411-034-0020(1)(a-d), 411-034-0070(1)(a-d), 411-034-0090(1)

7. Service transportation reduction- rides reduced
(contracted transportation provider)

Use SDS 540, not SPAN

Service transportation can only be authorized for reasons related to an individual’s safety or health when other resources, such as natural supports, volunteer transportation, or mail order and delivery, are not available. Your eligibility for service transportation was reviewed as a part of the recent assessment conducted with you on mm/dd/yy. Based on Oregon Administrative Rules, rides to the following locations can no longer be provided to: insert location. Therefore, the number of rides authorized per month through transportation provider name is being reduced from xx rides to xx rides per month.

Oregon Administrative Rules: 411-030-0055(1) through (6)

8. Reduction in the number of exception hours approved and denial of request for in-home exception hours

 

Use SPAN (SDS 2780N). Include an explanation for the reduction and/or denial of in-home reduction hours.

See APD-PT-18-031, APD-PT-18-042, APD-PT-18-048, APD-PT-18-046

9. Increase in pay-in for in-home support services

Use the SDS 540P

See APD-PT-18-031, APD-PT-18-042, APD-PT-18-048 on information to use SPAN

Note: Home delivered meals is calculated as part of the individual’s pay-in, so if the meal costs go up, then a 540P should be sent to notify of increased pay-in.

10. Increase in liability for CBC facility or NF

Use SDS 540P or 458A, not SPAN

Note: For NF, the 458A from the DHS Forms Server can serve as an adequate notice (the OA version does not unless rule numbers and hearing rights are included)

You are responsible for contributing to the cost of your long-term care services. The Department found that your insert reason: (insert type of income) increased from $XX to $XX per month or, the amount of income diverted to your spouse has decreased from $XX to $XX, etc. The new amount of your liability is $__________ per month.

Oregon Administrative Rules 461-160-0610, 461-160-0620

11. Reduction of hourly service hours due to ineligibility for shift services

Use SPAN Shift Services section.

See APD-PT-18-031, APD-PT-18-042, APD-PT-18-048

12. Spousal Pay closure due to ineligibility for spousal pay program (still eligible for in-home services)

Copy appropriate language into SPAN.

See APD-PT-18-031, APD-PT-18-042, APD-PT-18-048

If you are reducing for a different reason, please insert appropriate reason, along with OARs, or consult with Central Office.

  1. You have applied for the Spousal Pay Program. You do not require full assistance in four of the six activities of daily living (Mobility, Eating, Cognition, Dressing/Grooming, Elimination, and Bathing/Hygiene). Therefore, you are not eligible for this program.

Oregon Administrative Rules 411-015-0005(2); 411-015-0006; 411-015-0100(2); 411-030-0020(53); 411-030-0080(2)

  1. You have applied for the Spousal Pay Program. You are not eligible for this program because:
    • You are not assessed as a full assist in Mobility, Elimination, or Cognition; and
    • You do not have a debilitating medical condition, a spinal cord injury or similar disability with permanent impairment; or
    • An acute care or hospice need that is expected to last no more than six months.

Oregon Administrative Rules 411-015-0005(2); 411-015-0006; 411-015-0100(2); 411-030-0020(53); 411-030-0080(2)

Special Needs Closure

1. No longer eligible for payment for food for guide dogs and special assistance animals

You are no longer eligible to receive a payment of $insert amount for food for guide dogs or special assistance animals as you no longer have a guide dog or special assistance animal/ are no longer receiving SSI [and/or] your adjusted income is not below the OSIPM income standard/ are no longer receiving home or community-based care/ are no longer receiving OSIPM benefits. OAR 410-120-1210,461-155-0500, 461-155-0530.

2. No longer eligible for laundry allowance

You are no longer eligible for a monthly laundry allowance of $insert amount because you no longer receive SSI [and/or] your adjusted income is not below the OSIPM income standard/ no longer receive OSIPM/ no longer have proven excessive coin-operated laundry facility costs/ have moved to an [adult foster home/assisted living facility/ nursing facility/ residential care facility/specialized facility that is not apartment-based]/now have your own laundry facilities. OAR 410-120-1210, 461-155-0500, 461-155-0580.

3. No longer eligible for ongoing CBC room and board payment You are no longer eligible for the community-based care special needs payment to pay your room and board cost to the community-based facility. The payment is the difference between the OSIPM income standard for one person and your total countable income [including income applied to you from your spouse] and [your/your spouse's] total countable income is now above the OSIPM income standard. OAR 410-120-1210, 461-155-0500, 461-155-0630
4. No longer eligible for supplemental telephone allowance

You are no longer eligible for a supplemental communication allowance because you are no longer receiving SSI [and/or] your adjusted income is not below the OSIPM income standard/ are no longer receiving in-home services/ are no longer unable to leave your residence without assistance/ are no longer receiving OSIPM benefits. OAR 410-120-1210, 461-155-0500, 461-155-0680

*Note: If the Department is paying the ongoing monthly cost for an Emergency Response System (e.g. Oregon Lifeline) add the following before the list of OARs:

This allowance covered the ongoing monthly cost of your Emergency Response System. We have notified insert vendor name that effective mm/dd/yy, the Department will no longer make payment for this system. Please arrange with vendor name to begin paying privately or return your equipment.

6. No longer eligible for payment for prescription drug co-pays You are no longer eligible to receive the monthly payment of $amount for your Medicare Part D/Veteran's prescription co-pays because you no longer receive SSI/your prescription co-pays do not total $10 or more each month. OAR 410-120-1210, 461-155-0500, 461-155-0688
7. No longer eligible for in-home supplement You are no longer eligible to receive the In-Home Supplement payment of $22 per month because you are no longer receiving SSI as your only source of income/in-home services/State Plan Personal Care services/DD in-home or community-based care services. OAR 410-120-1210, 461-155-0500, 461-155-0575
8. No longer eligible for PIF and room and board allowance You are no longer eligible for a personal incidental fund and room and board allowance because your countable income is more than the OSIPM income standard/[you/your] spouse's income has increased and your spouse can now meet [his/her] monthly expenses without the allowance/you no longer reside in a community-based care facility/you are no longer eligible for home and community-based services. OAR 410-120-1210,461-155-0500, 461-155-0700, 461-160-0620
9. Special Diet Allowance Closure

Effective mm/dd/yy, you are no longer eligible for a monthly special diet allowance because you no longer receive SSI and your adjusted income is not below the OSIPM income standard / you no longer receive in-home services / you no longer receive OSIPM / you did not provide current documentation requested on mm/dd/yy due by mm/dd/yy (insert one of the following:

  • from a medical authority showing you must adhere to a special diet, your specific nutritional need and that you would be in an imminent life-threatening situation without the diet
  • from a licensed dietitian showing your current diet items being replaced or removed, the special diet items being added to your diet and the recommended quantity of each special diet item
  • verifying the monthly cost for any current diet item being removed or replaced and the monthly cost of any special diet items being added
  • verifying the monthly cost of your special diet)

Special Needs Reduction

1. Reduction of prescription co-pay payments

Your monthly payment of $amount for your Medicare Part D/Veteran's prescription co-pays will be reduced to $amount effective mm/dd/yy based on the reduced monthly costs you provided on mm/dd/yy.

OAR 410-120-1210, 461-155-0500, 461-155-0688

2. Reduction of PIF and room and board allowance Your monthly payment of $amount for a personal incidental and room and board allowance will be reduced to $amount effective mm/dd/yy because your/your spouse's income, which the Department uses to calculate your benefit has increased. OAR 410-120-1210,461-155-0500, 461-155-0700, 461-160-0620
3. Special Diet Allowance Reduction

Effective mm/dd/yy, your monthly special diet allowance will be reduced to insert new amount because the cost of your special diet has decreased.
OAR 410-120-1210, OAR 461-155-0500, OAR 461-155-0670

Special Needs denial

1. Denial of payment for guide dog or assistance animal food You are not eligible to receive a payment for food for your guide dog or special assistance animal because your animal is a companion animal and has not been specifically trained to perform tasks to meet your specific medical needs or specific physical tasks that you are unable to do in order to sustain your independence. OAR 410-120-1210, 461-155-0500, 461-155-0530(1)(3)
2. Denial of laundry allowance Your are not eligible for a monthly laundry allowance because you do not receive SSI [and/or] your adjusted income is not below the OSIPM income standard/ you do not have proven excessive coin-operated laundry facility costs/ you reside in [an adult foster home/an assisted living facility/ a nursing facility/ a residential care facility/a specialized facility that is not apartment-based]/you have your own laundry facilities. OAR 410-120-1210,461-155-0500, 461-155-0580
3. Denial of payment for home repairs

You are not eligible for a payment for home repairs because, you are not the homeowner or joint owner of the dwelling / the repair is not necessary to remove a physical hazard to your health and safety/the repair cost is more than the cost of moving to another home/the use value is not consistent with your service plan/you have not provided three competitive bids for the repairs and there are three or more providers available in your area/ the provider did not complete the work within current building codes/the work was not completed by a licensed and bonded construction contractor. OAR 410-120-1210,461-155-0500, 461-155-0600

Payments for home repairs are limited to $1,000 in any 24-month period; furthermore, if the home is jointly owned, you are not on services, and the other owner is not your spouse, the payment is pro-rated based on the percentage of home ownership. You are not eligible for a payment for home repairs because you have already exceeded the maximum benefit within the last 24 months. You will not be eligible for this benefit again until mm/dd/yy. OAR 410-120-1210, 461-155-0500, 461-155-0600

4. Denial of payment for moving costs

You are not eligible for a payment for moving costs because your move was not a result of hazardous housing, domestic violence, or eviction for reasons other than non-payment of rent/ your needs would not be better met out of state/your level of services has not increased or decreased to the extent that it is necessary for you to move from your current living situation. OAR 410-120-1210, 461-155-0010, 461-155-0500, 461-155-0610.

You are not eligible for a payment for moving costs. Payments for moving costs are limited to $1,000 and for no more than one move in any 12-month period. You received $amount for a move in mm/yy, which is within the last 12 months. OAR 410-120-1210, 461-155-0500, 461-155-0610

5. Denial of supplemental communication allowance

You are not eligible for a supplemental communication allowance/payment for an Emergency Response System because you do not receive SSI [and/or] your adjusted income is not below the OSIPM income standard/you are not receiving in-home services and are not unable to leave your residence without assistance due to a documented medical condition. OAR 410-120-1210,461-155-0500, 461-155-0680

6. Denial of payment for prescription co-pays You are not eligible for a payment for your Medicare Part D/Veteran's prescription co-pays because your verified co-pays are less than $10 per month/you are not an SSI recipient. OAR 410-120-1210,461-155-0500, 461-155-0688
7. Special Diet Allowance Denial

You are not eligible for a monthly special diet allowance because you do not receive SSI [and/or] your adjusted income is not below the OSIPM income standard / you do not receive in-home services /
you did not provide documentation requested on mm/dd/yy due by mm/dd/yy (insert one of the following:

  • from a medical authority showing you must adhere to a special diet, your specific nutritional need and that you would be in an imminent life-threatening situation without the diet
  • from a licensed dietitian showing your current diet items being replaced or removed, the special diet items being added to your diet and the recommended quantity of each special diet item
  • verifying the monthly cost for any current diet item being removed or replaced and the monthly cost of any special diet items being added
  • verifying the monthly cost of your special diet)


OAR 410-120-1210, OAR 461-155-0500, OAR 461-155-0670

 

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Oregon Department of Human Services
500 Summer St. NE E02, Salem, OR 97301-1073
Phone: (503) 945-5811
Toll-free: (800) 282-8096 (V/TTY)