To be eligible for medical assistance, people must be residents of Oregon. They must be currently living in Oregon and intend to remain in the state. There is no requirement that they must have been in Oregon or intend to remain in the state for a minimum amount of time. Residents can leave the state for temporary purposes (e.g., vacation, school attendance, medical treatment, employment) and keep their residency as long as they intend to return to Oregon.
A new resident receiving medical assistance from another state may receive duplicate medical assistance from Oregon if the person would be eligible in Oregon and would not otherwise receive medical care. Medical benefits may be authorized for an eligible client if an Oregon provider refuses to bill another state and the client would not otherwise receive medical care.
Residency Requirements: 461-120-0010
Statement of Intent to Reside: 461-120-0050
Duplicate Benefits: 461-165-0030
State of Residence for People in a Medical Facility. Residency of an individual living in a state or private medical facility such as a hospital, mental hospital, nursing home, or convalescent center is determined as follows:
To be eligible for medical benefits, all applicants (except CAWEM applicants) must be a U.S. citizen or meet the alien status requirements. CAWEM applicants are not required to declare or provide proof of their citizenship or immigration status. Nonapplicants do not have to meet the citizenship or alien status requirement. Nonapplicants are not required to declare or provide proof of their citizenship or immigration status. The disclosure of information regarding citizenship and alien status for nonapplicants is voluntary.
Medicaid clients must verify citizenship except some clients are considered to have met the U.S. citizenship documentation requirements already and do not need to provide evidence of citizenship:
To be eligible for the CAWEM program, a client must be ineligible for MAA, MAF, OHP or OSIPM solely because they do not meet citizenship or alien status requirements.
To qualify for OHP, a person must be one of the following:
A U.S. citizen includes the following:
For information on sponsored noncitizens see the CAF Family Services Manual Section 9.
A qualified noncitizen meets the alien status requirement if they are one of the following:
Regardless when they were admitted, a person with one of the following designated statuses:
Regardless of when they were admitted, a qualified noncitizen who is:
The following meet the alien status requirements:
See the noncitizen chart in SPD Worker Guide D.1.
Citizen/Alien Requirements: 461-120-0110
Noncitizen status: 461-120-0125
All lawfully admitted aliens are given an INS document showing their legal status in the U.S. People who are lawful permanent residents are given an Alien Registration card (I-551). If they entered the U.S. as a lawful permanent resident, they would either have a visa in their passport or an I-94 as temporary evidence of their lawful permanent residence. Refugees, asylees and parolees are given an I-94 initially and an I-551 after they have been granted lawful permanent residence. All these documents will indicate they are authorized to work. Whether it is an I-551, I-94 or I-688B, it bears the cardholder’s alien registration number. All eligible alien status must be verified through SAVE or through the Immigration and Naturalization Services (INS) via a G845S form.
When a caretaker applies for a child, the caretaker must declare the citizen/alien status for themselves and the children they are applying for. They sign, under penalty of perjury, that the information they give is true. If the caretakers are parents of the children, each parent must sign for him/herself.
For more information on INS status codes, see the CAF Family Services Manual, Worker Guide Noncitizens-2: Citizen Alien Status.
A lawful permanent resident who would meet the noncitizen status requirement except for a determination by SSA he or she has fewer than 40 quarters of coverage may be provisionally certified for SNAP benefits while SSA investigates the number of quarters creditable to the client. A client certified under this section who is not eligible for SNAP benefits received while provisionally certified.
The provisional certification starts according to the rule on effective dates for opening benefits (461-180-0080). The provisional certification cannot run more than six months from the date of the original determination by SSA that the client does not have sufficient quarters.
Statement of Status: 461-120-0130
Amnesty Aliens: 461-120-0160
To be eligible for medical benefits, all applicants (except assumed eligible newborns and CAWEM applicants) must provide a SSN or verify they have applied for one as a condition of eligibility.
Applicants who do not have to meet the SSN requirement include:
Nonapplicants do not have to meet the SSN requirement. It is only on a voluntary basis that a nonapplicant provide their SSN. Nonapplicants are persons who choose not to apply for benefits or who are not eligible to receive benefits, even though they may be required to provide verification of income and resources.
If an applicant has not been issued a SSN, assist the applicant in applying for a SSN. If an applicant does not recall their SSN, assist the client in verifying the number.
Do not deny or delay medical benefits to an otherwise eligible applicant pending the issuance or verification of an individual’s SSN. However, if an applicant required to meet the SSN requirement refuses to apply for or provide an SSN, the applicant is not eligible for benefits.
SSN Requirement: 461-120-0210
Newborn Requirement: 461-120-0230
To be eligible for medical assistance, people must actively pursue assets for which they have a legal right or claim, i.e., unemployment compensation, workers compensation, Social Security Benefits, or any third party which may be liable for payments. However, people applying for one of the Department’s programs are not required to apply for other programs administered by the Department (e.g., QMB clients are not required to apply for SNAP).
To pursue assets, they must apply for and satisfy all requirements to receive benefits from other programs. They must also pursue legal remedies to obtain assets from any other source if they can secure legal counsel on a contingency fee basis. People do not have to pursue loans.
People without good cause who do not pursue assets they may be entitled to are not eligible for medical assistance. This ineligibility ends when they provide evidence that they are willing to cooperate. Only the individual who can pursue the asset is assessed the penalty and loses medical eligibility. Other individuals in the benefit group, such as other adults or children, continue to receive medical assistance.
To be eligible for medical assistance, adult members of the benefit group must pursue available health care coverage and cash medical support for members of the benefit group.
Cooperation in pursuing medical coverage includes, but is not limited to, applying for, accepting and maintaining all available cost-effective medical coverage and identifying and providing information to the Department in obtaining benefits.
Pregnant women are excused from cooperating in obtaining medical coverage. Other persons can be excused for good cause from pursuing medical coverage.
Persons (except pregnant women and persons excused for good cause) eligible for medical assistance are required to:
Persons (except for pregnant women, OHP-CHP eligible individuals, OHP-OPU eligible individuals and persons excused for good cause) eligible for medical assistance are required to apply for, accept and maintain cost-effective employer-sponsored health insurance.
Insurance is considered cost-effective when the employee’s share of the premium is equal to or less than the Cost-Effective Health Insurance Premiums (HIP) standard. If the insurance is not cost-effective, the person cannot be required to apply for or accept the insurance.
In the OHP-OPU program the following applies:
Eligibility under the OHP-OPU program ends and the person receives assistance for the health insurance premiums under FHIAP. If not eligible for FHIAP, the person is not required to enroll in their employer’s insurance and, if otherwise eligible, continues to receive benefits under the OHP-OPU program.
For OHP-OPU applicants, cooperation means providing information to the Department regarding their employer’s health insurance. For OHP-OPU recipients, cooperation includes, but is not limited to, providing information to FHIAP staff for determining FHIAP eligibility and applying for and accepting the health insurance once determined eligible for a subsidy under FHIAP. All OHP-OPU recipients must enroll in the health insurance if eligible under FHIAP.
People who do not cooperate and do not have good cause, are not eligible for medical assistance. There is no ineligibility for pregnant females who refuse to cooperate. Additionally, only the individual who can legally assign rights and obtain the insurance is assessed the penalty for failure to meet this requirement, or in other words, loses medical eligibility. The other individuals in the group, such as other adults and children, continue to receive Medicaid.
Ineligibility for medical assistance ends when the person provides evidence that they are willing to cooperate. A person can be penalized only if he or she has the legal right to obtain the health insurance.
Good cause for not cooperating includes, but is not limited to, the following:
People who claim good cause for refusing to cooperate on grounds other than those listed above, have 20 days from the date of refusal to provide the statement or evidence. If they have difficulty getting evidence, allow a reasonable time to provide the information. Consider them to have good cause if they have made a good faith effort to provide verification but are unable to do so.
Medical cooperation: 461-120-0345
Medical assignment: 461-120-0315
Requirement to pursue assets: 461-120-0330
Good cause for failure to cooperate: 461-120-0350
When determining eligibility for OHP medical assistance, use the following age requirements for each OHP category:
OHP Child: 461-001-0000
Age Requirements: 461-120-0510
Regular School Attendance: 461-120-0530
Pregnant women who are receiving benefits the day the pregnancy ends are assumed eligible for OHP (except OHP-CHP) until the last day of the calendar month in which the 60th day after the last day of the pregnancy falls.
A pregnant woman who was eligible for and receiving medical assistance under any Medicaid program and becomes ineligible while pregnant is assumed eligible for Medicaid until the last day of the calendar month in which the 60th day after the last day of the pregnancy falls.
A child born to a mother eligible for and receiving OHP (except OHP-CHP) benefits is assumed eligible for medical benefits until the end of the month the child turns one year of age.
People determined eligible for OHP are not eligible for retroactive medical assistance.
To qualify for medical assistance under OHP, a person cannot:
OHP includes five categories of people who may qualify for medical assistance. The first category is used to determine eligibility for nonpregnant adults who are 19 years of age and older. Eligibility for pregnant women is always determined using the fourth category.
There are additional categories used to determine eligibility for children. Always determine eligibility for children beginning with the second category, OHP-OPC, before moving on to the other three categories. If the family’s income exceeds the OHP-OPC income limit (100%), determine if the children might qualify under other categories, such as OHP-OP6, OHP-OPP or OHP-CHP.
Specific requirements: 461-135-1100
This category includes uninsured non-pregnant adults who are in a filing group with income under the (OHP-OPU) 100% income limit.
To be eligible for OHP-OPU, a person must be 19 years of age or older and must not be pregnant. An OHP-OPU person is referred to as a health plan new/noncategorical (HPN) client.
Effective July 1, 2004, the OHP-OPU program requirements were changed to limit the number of clients allowed into the program. The change was made to meet state budget requirements. The new limitations apply to OHP-OPU clients and CAWEM clients whose eligibility is based on OHP-OPU.
There are three groups of medical applicants that may be considered for OHP-OPU:
"Without a break in assistance" means that the OHP-OPU client requesting recertification returned their OHP recertification packet before their current certification expired.
"Without a break in assistance" also means a client converting from child welfare medical, BCCM, MAA, MAF, EXT, OHP-CHP, OHP-OPP, OHP-OPU, OSIPM, REFM or SAC applied for medical benefits while still receiving their prior medical program benefits. It could also mean that their worker reevaluated the client’s medical eligibility because of a reported change or eligibility review.
Example: Tina is a single adult who is not pregnant, has no children, and is not disabled. She is currently not receiving benefits under any DHS medical program. She requests medical on July 6, 2004. She may not be considered for OHP-OPU.
Example: Curt is a single adult who is receiving OHP-OPU. His certification ends on August 31. Curt turns his recertification in timely in August. Since Curt has reapplied timely, he can be considered for OHP-OPU.
Example: Larry is receiving OHP-OPU and his children are receiving OHP-OPC. His certification ends on August 31. He turns in his recertification late on September 1. His family is not eligible for any other program. Although his children can be considered for OHP, Larry cannot be considered for OHP-OPU.
In addition to other OHP eligibility requirements, an OPU client:
Specific requirements 461-135-1100
OHP-OPU; Effective Dates for the Program 461-135-1102
When an OHP-OPU benefit group includes one or more nonexempt persons, a monthly premium is billed to the household. All clients eligible for OHP-OPU, if not exempt, are responsible for payment of premiums. Clients are exempt from paying a premium if they meet one of the following:
The amount of the premium is determined in accordance with 461-155-0235.
Once the amount of the premium is established, the amount does not change during the certification period unless one of the following occurs:
A premium is considered paid on time when the payment is received by the OHP Billing Office on or before the due date which is the 20th day of the month for which the premium was billed. The day the payment arrives in the OHP Billing Office’s post office box when sent via email or the day it is submitted via telephone or electronically to the billing office is the date it is received. A premium is past due when it has not been paid within 6 months of the due date.
Once determined eligible, OPU clients cannot be found ineligible for benefits during a certification period for premiums in arrears and past due premiums. Past due premiums and those in arrears only affect eligibility at certification and recertification.
A nonexempt OPU client can be found ineligible for not paying premiums as follows:
Unpaid Premiums. When applying or reapplying under the OPU program, a nonexempt applicant must pay all billed premiums to be eligible. Premiums must be paid before the applicant can be recertified. Include the requirement to pay premiums on the pend notice. If the unpaid premiums are not resolved within the 45 days from the date of request, deny medical assistance for that applicant.
Past arrearage can be canceled if the arrearage was incurred while the person was exempt from the requirement to pay a premium. As of June 1, 2006, clients with OHP countable income of 10 percent or less of the FPL when the premium is calculated, American Indians and Alaska Natives, and clients eligible under the CAWEM program are exempt.
The Department cancels any premium arrearage over three years old.
The computer determines the amount of the monthly premium by determining the number of persons in the need group, their average monthly income, and the number of nonexempts in the benefit group.
Premiums are collected by the Oregon Health Plan Premium Billing Office. OHP premium bills will state where and how to send in payments.
OHP Premium Billing Office
PO Box 1120
Baker City, OR 97814
Payments should be made by check, money order, or cashier’s check. People who come to a branch office wanting to pay their premiums should be told to send payments to the above address. Their premium notice includes a return envelope. For questions about the billing (whether a payment was received, etc.), call the OHP Billing Office at one of the numbers listed on the billing notice toll-free 800‑647-2029, or TTY 800-264-6958.
Premium requirement 461-135-1120
Specific requirements: 461-135-1100
Premium amount: 461-155-0235
These are persons under the age of 19 in an filing group with income under 100% of the income limit. If income is at or above 100%, the person may qualify at either the OHP-OP6 (133%) or OHP-CHP (185%) level. However, assumed eligible newborn children under the age of one who are at or above the OHP-OP6 (133%) are to be coded OHP-OPP and not OHP-CHP.
Specific requirements: 461-135-1100
These are persons under the age of six in a filing group with income over the OHP-OPC (100%) income standard, but below the OHP-OP6 (133%) income limit.
Specific requirements: 461-135-1100
This category includes pregnant females in a filing group with income below the 185% income limit and their assumed eligible newborn children at or above the OHP-OP6 (133%) income limit.
These are children who may qualify for medical assistance under the Children’s Health Insurance Program (CHIP) provision of the federal Balanced Budget Act of 1997. They are children under the age of 19 who are not eligible under the OPC, OP6 or OPP categories. Their financial group’s income must be below the OHP-CHP (201%) income standard.
OHP-CHP children must meet all the following special requirements:
If a child in a hospital becomes ineligible for OHP because they no longer meet the age requirement for their category, they can continue to be eligible for OHP until the end of the month in which they are discharged from the hospital.
Remember the parents of CHIP children should never be forced to apply for, accept and maintain other health insurance coverage as this is not an eligibility requirement in the CHIP program like it is Medicaid.
Specific requirements: 461-135-1100