Department of Human Services

Seniors and People with Disabilities Services

Human Services Building

Salem, OR 97301

SPD Program Manual Letter: #19

Effective Date: February 1, 2003

Reference: Administrative Rules Manual Letter #26

Major Changes

Implementation of OHP2

New federal Medicaid waivers changed the Oregon Health Plan (OHP) in a variety of ways. The basic benefit package is renamed as the OHP Plus benefit package. Individuals eligible under OHP (except for HPN clients), OSIPM (except OSIPM-MN) and BCCM receive the OHP Plus benefit package. A new benefit package called OHP Standard is created for individuals eligible under the Oregon Health Plan medical program as HPN (health plan new/non-categorical) clients.

All of the OHP medical assistance program names (along with their respective case descriptors) are changed and redefined as follows:

• OHP-OPU - Non-Pregnant adults eligible under the 100% income standard. These clients are also referred to as HPN (Oregon Health Plan new/non-categorical) clients.

• OHP-OPC - Children eligible under the 100% income standard.

• OHP-OP6 - Children under the age of six and eligible under the 133% income standard.

• OHP-OPP - Pregnant females eligible under the 185% (increased from 170%) income standard and their newborn children.

• OHP-CHP - Uninsured children eligible under the 185% (increased from 170%) income standard. OHP A.2.

The definition of a child for OHP medical assistance programs is simplified to be a person under the age of 19. An 18 year-old client is no longer required to attend school to still be considered a child. Also, the requirement to live with a parent or caretaker relative is dropped from the definition. Glossary

OHP medical assistance program budgeting is changed. Countable income is determined using the income from the three months preceding the month of application (budget month). Eligibility using the budget month income only continues for the same groups as before. E.6

Receiving medical assistance under the OHP program and receiving assistance from the Family Health Insurance Assistance Program (FHIAP) is prohibited. D.15

The following changes are specific to people eligible under OHP-OPU (also referred to as HPN clients):

• An HPN client must be uninsured to be eligible for OHP. Specifically, an HPN client must not be covered by private major medical health insurance and must not have been covered by private major medical health insurance in the preceding six months. The six month waiting period can be waived as in the CHIP program.

• An HPN client has the new requirement to pursue assistance from Family Health Insurance Assistance Program (FHIAP) if health insurance is available through his or her employer but the client has not yet enrolled in the insurance. If eligible for FHIAP, OHP eligibility ends and the client receives medical coverage through the employer’s insurance while receiving a subsidy from FHIAP.

• When an HPN applicant is identified as having access to (but is not enrolled in) group health insurance through his or her employer, a referral must be made to FHIAP. The FHIAP referral process is described in detail in a new section.

• The OHP premium requirement for HPN clients is changed. All premiums billed after February 1, 2003, must be paid timely. To be considered timely, the payment must be received by the OHP Billing Office on or before the 25th of the month following the month in which it is due. Failure to pay the premium in full on or before the 25th of the month will result in a six-month disqualification period for all HPN clients in the benefit group. The HPN clients cannot be found eligible for OHP until all unpaid premiums are paid and the six-month disqualification period has ended.

• The OHP premium standard table is changed to reflect the amount each non-exempt HPN client will be billed representing an increase in the total amount billed for many cases.

• Because of changes to the OHP premium policy, an HPN client may choose not to be a member of a benefit group when applying. Once certified eligible for OHP, the client must have premiums paid through the current month before he or she is allowed the choice of not being a member of the benefit group.

• Because an HPN client must be uninsured to be eligible for OHP, an HPN client is no longer eligible for reimbursement of cost-effective, employer-sponsored health insurance premiums (HIP). D.10

Presumptive Medicaid Disability Determination Team

Updated the OSIP Worker Guide 4 to reflect changes to the presumptive Medicaid disability determination process.