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Staff Tools | OHP Program Manual | C. Eligibility
OHP Program Manual
C. Eligibility Groups
1. Household Group
The household group is the people who live together with or without benefit
of a dwelling. For homeless people, the household group is the people who consider
themselves living together. A dwelling can contain more than one household if
it is divided into separate living units, such as an apartment house, or if
a landlord/tenant relationship
When people live in more than one household during a month, they are considered
to be living in the household where they spend 51% or more of their time.
A person who leaves the household for short periods is considered to still
be in the household if they intend to return. People gone from the household
for 30 days or more are no longer part of the household, except for the following:
- Individuals in an acute care medical faclity
remain in the household group unless they go into long-term
- A caretaker relative who is gone for up to 90
days while in a residential alcohol or drug treatment facility are in the household
- An individual who is absent because of education, training, or employment, including long-haul truck driving, fishing, and active duty in the U.S. armed forces.
- A child who is absent for 30 days or more are is in the household group if the child is one of the following:
- Absent for illness (unless the child is in a long-term care Title XIX facility), social service, or educational reasons.
- In foster care, but expected to return to the household within the next 30 days.
- In a residential alcohol or drug treatment facility. If the household of the child is ineligible because of income, the child is a separate household.
2. Filing Group
The filing group is the people in the household group whose circumstances are
considered in the eligibility determination process. A household group
member of any age must be in their own filing group if they are not required
to be in a filing group with other household group members.
The following people
living in the household must be included the same filing group:
- Individuals legally married to each other and
each child of either spouse.
- Each parent of a child
or unborn and the children of each parent.
- Each sibling under the age of 19.
A caretaker relative (defined in 461-001-0000)
has the option of forming a separate filing group for children living in the
household who are not their own children, or including the children in the caretaker
relative’s filing group.
Each person in the household who is applying for OHP, regardless of their age,
who is not required or allowed to be included in the filing group with other
people, must be an individual filing group.
A child receiving OHP benefits with his or her parents must apply separately
upon reaching age 19 if he or she wants to continue to qualify for medical assistance.
The following people are assumed to be eligible for OHP:
- Pregnant women who are receiving
medical assistance under any other program and become ineligible while pregnant.
They are eligible for OHP (except OHP-CHP) if their income was under the OHP
income standard while they were pregnant and receiving benefits.
- Pregnant women receiving OHP-CHP when their pregnancy ends.
They continue to be eligible until the last day of the calendar month in which
the 60th day after the last day of pregnancy falls.
- A child born to a mother who is eligible for and receiving
OHP (except for a child born to a CAWEM mother). The child is eligible until
the end of the month in which the child becomes one year old, as long as the
child is continuously a member of his or her mother’s household group.
- Note: A person under 19 who is pregnant and has
income above 100% FPL should be coded OHP-OPP rather than OHP-CHP.
- Note: A child born to a CAWEM mother is not an
assumed eligible newborn. However, the child should be added to the case for
the remainder of the certification period without an application. The child’s
eligibility will be evaluated when the household reapplies.
Filing Group: 461-110-0400
Assumed Eligibles: 461-135-0010
3. Financial Group
The financial group is the filing group members whose income and resources
count in determining eligibility and benefits. The financial group for OHP consists
of all the people in the filing group (including those receiving SSI benefits),
except caretaker relatives (other than parents) who choose not to be included
in the need group.
4. Need Group
The need group is the people whose basic and special needs are used in determining
eligibility. For OHP, the need group consists of all the people in the financial
group. For pregnant females, include the unborn child(ren).
5. Benefit Group
For people not assumed eligible (461-135-0010), the benefit group
consists of the people from the need group requesting benefits who:
- Meet all nonfinancial eligibility requirements;
- Have resources below the resource limit; and
- Have income below the Income Limits/Payment Standards.
For people assumed eligible, the benefit group consists of the
people who are in the benefit group of the program used to assume eligibility.
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