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OHP Program Manual

B. Application

Effective 3/01/11

1. Overview

People who apply for OHP medical assistance and another program (e.g., Food Stamps) use the SDS 539A (Application Form) for both programs. When applying for OHP only, they use the OHP 7210 (Application for the Oregon Health Plan), OHP 7210R (Reservation list) or OHP 7210W (online version).

arrow For more information on the reservation list, see 461-135-1125.

2. Date of Request

To apply, a person or someone authorized to act on their behalf must either contact a branch office serving the area they live in, an outreach center, or call the toll-free number 1-800-359-9517, with a request for benefits. A request may be in the form of a phone call, a visit to the office, online or in writing. When the online OHP 7210W application is submitted online, it is time-stamped and a DOR established for the applicant.

The DOR starts the application process.

The date of request is the determined as follows:

Hospitals call the OHP Application Center to establish a date of request (used to be called a “hospital hold”) when an individual is admitted. To find out if there has been a date of request for the applicant, call the OHP Application Center at 1-800-359-9517.

Date of request: 461-115-0030
Where clients can apply: 461-115-0150

3. Application Requirements

A person or family may use an authorized representative to complete the application for them if needed. If needed, the branch may appoint a responsible person to be the authorized representative.

When an application is required. New medical program applicants must complete a new application. For ongoing clients, an application will not be required in most situations.

A new application is not required:

When there is a parent in the household group, one parent must sign the application. When there is no parent in the household group, the primary person must sign the application.  

Although clients are not required to have a fixed mailing address, they must provide a location to get notices from the Department. This mailing address cannot be the branch address. For the homeless, the mailing address may be General Delivery or the address of a shelter or a friend.

People may withdraw their application at any time.

Application processing timeline. The application is complete when the person completes and signs the application and provides the necessary information and verification within 45 days from the date of request. The Department determines eligibility and sends a decision notice not later than the 45th day after the date of request (do not deny before the 45th day).

The Department may extend the period if one or more of the following applies:

Do not require an interview for medical applicants. If the client no shows a SNAP appointment, do not deny the request for medical. Complete the medical application process through the mail and/or by phone as needed.

Once a person is determined eligible for OHP, any changes in the filing group’s household composition, income or resources, does not affect their eligibility during their current certification period. However, other changes (such as residency, citizenship, student status and failure to pay premium) can effect eligibility.

Healthy Kids implementation. The following procedure applies to children with a DOR of July 1, 2009 or later:

Determine eligibility for children using current medical policy. If a child is denied or closed, complete the denial or closure, but mail or shuttle a copy of the application to the OHP Statewide Processing Center.

arrow Click here for a cover sheet with the address. Multiple applications can be bundled.

Do not:

5503 will image the application. Once the October medical policy changes have been implemented, 5503 will redetermine eligibility. If not eligible using the October policy changes, 5503 will redetermine eligibility again using the January 2010 policy changes.

Application requirements: 461-115-0050
Authorized representative: 461-115-0090
Time frame: 461-115-0190

4. Certification Period

The certification period is as follows:

OPP certification. A pregnant woman eligible for OHP is not assigned an eligibility period. She is assumed eligible through the last day of the month in which the 60th day following her pregnancy falls. When her assumed eligibility period ends, she needs to reapply to continue to receive benefits even if the certification period for others in the group extends beyond her assumed eligibility period. The computer system uses the DUE need/resource date to determine the period of eligibility. If the pregnancy ends in a month other than the date coded, it is important to change the DUE need/resource date so the person receives the correct period of coverage.

In order not to have a break in benefits, an application must be submitted in the last month of the current certification period and eligibility determined within the application processing time frame.

Once a person is determined eligible for OHP, any changes in the filing group’s household composition, income or resources, does not affect their eligibility during their current certification period. However, other changes (such as residency, citizenship, student status and failure to pay premium) can effect eligibility.

Adding/removing persons. An additional application is not needed to add an assumed eligible newborn to a benefit group. To add anyone other than an assumed eligible newborn to the benefit group, the current application can be amended if the information is sufficient to determine eligibility; otherwise a new application is required. A new certification is needed when adding anyone other than an assumed eligible newborn. If the person wanting to be added to the benefit group is found ineligible, the benefit group completes their current certification.

When a new person (other than a newborn) wants to be added to an ongoing case, the entire group must establish a new certification period. If the new certification would make the current benefit group ineligible, the original benefit group remains eligible for the remainder of their certification period.

When a recipient moves into the household of another recipient, they must be combined into one case if all of the recipients are required to be in the same filing group. When cases are combined, extend the certification period to the latest date for any of the persons in the group.

When a person leaves an OHP benefit group, that person is still eligible through the end of the certification period as long as he or she meets the nonfinancial and specific program requirements. Those remaining in the original benefit group also are still eligible through the end of the certification period if they continue to meet the nonfinancial and specific program requirements. A different case will need to be opened for the person who left the group. If the person is paying premiums as required under the OHP-OPU program, the premium status from the original case will not be updated on the new case. If the person has unpaid premiums that would have resulted in a disqualification, the worker will need to add disqualification coding to the new case.

arrow For more information on the extension of a certification period using the BED code, see F.2.

Certification Period: 461-115-0530

When the Department initiates a redetermination of eligibility, the Department must review the filing group for other medical program eligibility prior to reducing or ending medical benefits. If additional information is needed to redetermine eligibility, the benefit group remains eligible from the date the review is initiated until the Department determines eligibility in accordance with the application processing time frames in 461-115-0190.

461-180-0085

5. Continuous Eligibility

OHP-CHP. When a pregnant child is eligible for and receiving OHP-CHP program benefits loses this eligibility, her medical assistance continues through the last day of the month in which the pregnancy ends as long as she is not a recipient of private major medical health insurance. Code this case a P2 with CEC case descriptor and need. Also code CEC in the Med prg field.

To be eligible for the continuous eligibility, a client must meet all of the following requirements:

  • Be a U.S citizen or qualified non-citizen (see 461-120-0125);
  • Be under 20 years of age;
  • Lose eligibility for OHP-CHP program medical benefits while pregnant; and
  • Not be a recipient of private major medical health insurance.

Continuous eligibility ends:

  • The last day of the month in which the pregnancy ends;
  • When the client moves out of state;
  • When the client voluntarily ends OHP-CHP program benefits;
  • When the client becomes a recipient of private major medical health insurance; or
  • If the client becomes eligible for CW medical, EXT, MAA, MAF, OHP, OSIPM, or SAC program benefits.
  • The date the client dies.

All other OHP programs (Medicaid). When a child who is eligible for and receiving OHP (except OHP-CHP) loses eligibility with time remaining in the 12-month continuous eligibility period, the child’s medical assistance continues for the remainder of the 12-month eligibility period. Code this case a P2 with CEM case descriptor and need. Also code CEM in the Med prg field.

To be eligible for the continuous eligibility, a client must meet all of the following requirements:

  • Be under age 19;
  • Be a U.S citizen or qualified non-citizen (see 461-120-0125);
  • Be receiving OHP Plus Medicaid benefits; and
  • Not have received Medicaid for 12 full months from initial application or most recent redetermination

Continuous eligibility ends:

  • When the client moves out of state;
  • When the client voluntarily ends OHP;
  • The end of the continuous eligibility period;
  • When the client turns age 19; or
  • When the client dies.

The continuous eligibility period is based on the most recent OHP program approval date. A child losing eligibility less than 12 months after having been approved for benefits qualifies for continuous program benefits for the balance of the 12 month period following that approval.

461-135-1149

 

6. Verification

The intent of verification is to ensure that the verbal or written information given by a person is true.

People must provide verification of eligibility when requested. Branch staff determine what is acceptable verification for specific eligibility requirements and situations. An application may be denied or ongoing benefits ended when acceptable verification is not provided; however, federal policy is clear that ongoing medical clients are “eligible until no longer eligible.” Be sure to list the reason(s) why eligibility needs to be verified on the pend notice. Do not forget to narrate the eligibility factor that needs verification.

Verify the following eligibility requirements for the initial application and when needed:

All of the following clients are exempt from the citizenship and identity verification requirements:

Verify the following at recertification:

Verify the following whenever it is reported, changed or as needed for eligibility determination:

For all other eligibility requirements (i.e., residence, age, resources) accept the person’s statement unless it is questionable or inconsistent.

Any eligibility requirement may require verification when information is questionable or inconsistent.

Verification of the occurrence of an act of domestic violence is not required for any program.

Required Verification: 461-115-0610 & 461-115-0705

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Oregon Department of Human Services
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Phone: (503) 945-5811
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