Special Considerations for Incarcerated Clients (HB 3536)

Updated 1/31/20

OAR 461-135-0950

House Bill 3536 mandates DHS/OHA suspend Medical benefits on any client who is receiving Medicaid and who becomes incarcerated at a local jail. This bill extends the process created under SB913, where benefits of clients who have a severe mental impairment were suspended.

An inmate is an individual who is:

• Confined involuntarily in a local, state or federal prison, jail, detention facility, or other penal facility, including a person being held involuntarily in a detention center awaiting trial or a person serving a sentence for a criminal offense;
• Residing involuntarily in a facility under a contract between the facility and a public institution where, under the terms of the contract, the facility is a public institution;
• Residing involuntarily in a facility that is under governmental control;
• Receiving care as an outpatient while residing involuntarily in a public institution; or
• In the OSIPM and QMB programs, released from the public institution during a temporary period of hospitalization in a medical institution outside of the correctional facility.
• Court ordered to live in a supervised community residential facility such as a halfway house or transition center.

 An individual is not an inmate when:  

• The person is released on parole, probation, or post-prison supervision;
• The person is on home- or work-release, unless the person is required to report to a public institution for an overnight stay; or
• The person is staying voluntarily in a detention center, jail, or county penal facility after his or her case has been adjudicated and while other living arrangements are being made for the individual.
• The person is court ordered to reside at Northwest Regional Reentry Center on the Aid & Assist program.

A public institution is any of the following:

• A state hospital (as defined by ORS 162.135) such as the Oregon State Hospital and any other hospital established by law for similar purposes, including the "SAIP" means Secure Adolescent Inpatient Program (SAIP), and the Secure Children’s Inpatient Program (SCIP). See section D.7 of the APD Worker Guide for exceptions to ineligibility for individuals entering the state hospital.
• A local correctional facility (as defined in ORS 169.005): a jail or prison for the reception and confinement of prisoners that is provided, maintained and operated by a county or city and holds persons for more than 36 hours.
• A Department of Corrections institution (as defined in ORS 421.005): a facility used for the incarceration of persons sentenced to the custody of the Department of Corrections, including a satellite, camp, or branch of a facility.
• A youth correction facility (as defined in ORS 162.135):
  • A facility used for the confinement of youth offenders and other persons placed in the legal or physical custody of the youth authority, including a secure regional youth facility, a regional accountability camp, a residential academy and satellite, and camps and branches of those facilities; or
  • A facility established under ORS 419A.010 to 419A.020 and 419A.050 to 419A.063 for the detention of children, wards, youth, or youth offenders pursuant to a judicial commitment or order.

As used in this rule, the term public institution does not include:

• A medical institution as defined in 42 C.F.R. 435.1009;
• An intermediate care facility as defined in 42 C.F.R. 440.140 and 440.150;
• A publicly operated community residence that serves no more than 16 residents, as defined in 42 C.F.R. 435.1009; or
• A child-care institution as defined in 42 C.F.R. 435.1009 with respect to:
  • Children for whom foster care maintenance payments are made under title IV-E of the Social Security Act; and
  • Children receiving TANF-related foster care under title IV-A of the Social Security Act.
• A supervised community residential facility such as a halfway house or transition center.
  • Note: Supervised Community Residential Facilities can be publicly or privately operated and often house residents with a variety of legal statuses. Some may be on probation and voluntarily residing at the facility (not inmates), others may be there as part of their sentencing (inmates), still others may be on work release (not inmates). It is important to gather information about the facility and resident to determine if the applicant is an inmate.

If this policy indicates that the medical benefits of a client are suspended, a client meeting the eligibility requirements of a program covered under chapter 461 of the Oregon Administrative Rules is not required to submit a new application for the benefits to be reinstated.

The Oregon legislature passed a bill in 2017 that removed the 12-month limit. Effective, when the individual is released, Medicaid will be reinstated if the Department is notified within 10 calendar days of the release, and client is still eligible for assistance; Medicaid eligibility is not extended to an ineligible person. For APD programs, not all clients will be eligible upon release. Clients who had been receiving home and community-based services may need a new assessment before benefits can be reinstated. If SSA has terminated Medicare benefits, a QMB client would need to provide verification that Medicare Part A has been reinstated or is still in effect before their QMB case can be reopened. No application is required to restart benefits, unless there is no application on file.

To reduce field staff workload, if OPAR receives incarceration information and the inmate has a projected release date within the current month, OPAR will take no action on the case. The effective date is the date the decision is made to suspend the benefits and the date the notice is sent.

OPAR will be taking the following actions on APD clients who become incarcerated and who have a release date after the current month. Unfortunately, if a case is put into 'Susmend' status it will auto-close in the mainframe system at the end of 12 months. There is no way to prevent the auto-closure without reopening or restoring the case, which we don't want to do until the individual is released and eligibility reestablished. This means that you will have to let the case remain in closed status and narrate that due to system limitations, the case appears closed but remains indefinitely suspended.

Inmate is Released Temporarily to a Hospital

Incarcerated clients who are released temporarily in order to receive treatment in a hospital or other medical facility can be eligible for medical benefits during the time that they are temporarily released.  5503 has a reporting process by which inmates who are temporarily released get medical procedures done, and they then determine eligibility for MAGI medical programs.  If the temporarily released client is not eligible for MAGI, 5503 will refer the client’s information to APD for a determination of OSIPM or Medicare Savings Programs. Please see below for more information on what actions to take.

Note: These procedures may be subject to change due to the 7/1/17 policy change making the suspension indefinite.

OPAR process for incarcerated clients

• Local jails and Department of Corrections (DOC) submit incarceration data to DHS twice a month. The incarceration information is used to identify recipients of SNAP and Medicaid benefits. When a client is identified as receiving SNAP or Medicaid benefits and is incarcerated, OPAR will take the following actions:
  • If there is just one person on the case (either SNAP or Medicaid) OPAR will take action. An exception to this is Medicaid cases coded with case descriptors APD, ICP, NFC, DAN or DDS or cases in pending status. These cases will be referred to Branch 5510, who will contact the financial worker or case manager handling the case. The financial worker or case manager will be responsible for susmending/closing those cases.
  • Medicaid cases will be 'susmended' and SNAP cases will be sent timely notice and closed when appropriate. OPAR will send Medicaid clients an auto generated notice. Click here for copy of notice. The notice is still in the process of being revised to reflect the 7/1/17 rule change.
  • OPAR will narrate action taken in ACCESS and field staff will be notified by tickler. Non-MAGI cases will have 913 case descriptor added. MAGI cases will have a DOC case descriptor.
  • If a case has more than one person on the case, it will be referred to Branch 5510 who will contact the appropriate field worker.
• Jails will be asked to inform clients who have had their benefits susmended to contact their local office. Inmates must contact the local office within 10 days of their release. If the client has been released and contacts the branch within 10 days, take these actions based on the specific type of case:
  • SSI recipient: Client was receiving SSI when they became incarcerated and was incarcerated for less than one year. If the individual is 65 or older, verify that there are no income or resource changes before restoring the case without an application. For those under 65 who were receiving SSI based on disability, we cannot require them to reapply for SSI, but also don't want to refer for MAGI if they plan to do so and will be approved. Contact PMDDT to verify that disability status is still valid, then reopen OSIPM without an application (as long as income and resource info hasn't changed). Remind the individual to report if he/she is approved for SSI. If the individual does not intend to reapply for SSI, refer for MAGI (leave OSIPM open until MAGI determination in complete).
  • Protected Eligibility Groups: (DAC/Pickle etc). If the case has been in susmend status for less than one year, reopen the case without a new application, and tell the client they need to contact SSA and let SSA know they have been released. The client must provide proof of SSA benefit restoration. If proof of reinstatement is not provided, determine eligibility for any other program.
  • PMDDT client: If the client is released prior to a medical review due date, reopen the case. If the client was incarcerated when the medical review was due, they will need to complete a new application and reapply for PMDDT and be redetermined to meet the disability criteria.
  • QMB/SMB/SMF: SSA does not maintain Medicare Part B eligibility for inmates. Typically an inmate will be released with Part A and no Part B Medicare. If this is the case, restore the case using an MIB 2 code. Contact the Buy-In unit via email (Buy-In.Medicare@dhsoha.state.or.us) and request Part B Buy-In. If the client has maintained Medicare eligibility while incarcerated, QMB can be restarted the beginning of the month following release and no new application is required, SMB/SMF would be restored the first of the month of release. If Medicare eligibility has ceased completely, the client will need to complete a new application when Medicare has been reinstated. Follow OAR guidelines to determine the effective date for beginning benefits.
  • Service cases: If the client is incarcerated for less than 30 days, the incarceration is not considered a break in services and Medicaid can be restored without a new assessment or a new application. If the client is incarcerated for over 30 days, a new period of care begins and the client will need a new assessment and a new application. 461-001-0030
  • EPD cases: If the client is incarcerated for less than 30 days and can verify continuing employment upon release, restore EPD case. If client is incarcerated less than 30 days and can not verify employment or is incarcerated over 30 days, they would no longer qualify for the EPD program and will need to complete a new application.
  • DOC case descriptor: Some MAGI CMS cases will have a DOC case descriptor put on the case when the client becomes incarcerated. If you need to convert one of these cases, you will need to get the DOC case descriptor removed. Branch staff are unable to remove this code. If you need to remove the DOC case descriptor (for instance to change the case to a D4) contact Cassandra Riley.

See SPD-PT-11-015

Process to susmend cases in local office:

• On the Medical Assistance tab in ACCESS choose incm code of SUSM. Use the date of incarceration as the effective date and MEDL ELIG end date.
• CMS will stay in Susmend status for 12 months, and will auto close at the end of 12 months.
• There is no way to prevent the auto-closure without reopening or restoring the case, which we don't want to do until the individual is released and eligibility reestablished. This means that you will have to let the case remain in closed status and narrate that due to system limitations, the case appears closed but remains indefinitely suspended.

If you have a disability and need a document on this Web site to be provided to you in another format, please contact the Office of Document Mangement (ODM) at 503-378-3486 or by e-mail at dhs.forms@state.or.us.

If you have questions about DHS or problems getting DHS services, send e-mail to dhs.info@state.or.us. If you have comments about this site, send e-mail to spd.web@state.or.us.

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)