DHS home | APD Staff Tools | OHP Program Manual | WG-1 Agreement on OHP Applications

OHP Program Manual

WG-1 Agreement Between 5503 and APD/AAA Offices Regarding Medical Applications

Effective 4/1/12

This Worker Guide describes the agreement between OHP branch 5503 and APD/AAA offices, and which office will carry certain cases.

Effective January 2008, DHS implemented a reservation list process for OHP Standard (OPU). People who are interested in applying for OHP Standard can add their name electronically to the reservation list at www.oregon.gov/DHS/open (which also has a link to submit by email) or by sending in the Reservation List request form (OHP 3203), or by calling the OHP Phone Bank at 1-800-699-9075.

A notification application, 7210P, is mailed each week to requestors whose names are added to the reservation list. The 7210P notification application does not have a reservation list number assigned to it, and should be treated like any other request for medical assistance. If the applicant submits a 7210P but has not been selected from the reservation list, rules regarding OHP-OPU eligibility apply.

When the requestor is selected from the reservation list, they will be mailed a 7210R with their reservation list number displayed on the application. The requestor has 45 days to establish a Date of Request (DOR) from either:

• their selection date, or
• their application date, or
• a verbal request to the local office

If the selected person completed and submitted an application within 45 days prior to their selection date, the submitted application can be used with the date of selection as the DOR. DHS will determine eligibility for all submitted applications and send the appropriate approval or denial notice.

Expectation: A local APD/AAA office receiving a medical application for a situation where they will not hold the case is expected to complete a courtesy intake and transfer the case to the appropriate branch after processing.

Case 'Ownership'

In general, SS branches carry OHP cases in which there is a companion SS case (either medical or SNAP).

In general, APD/AAA branches carry OHP cases in which there is:

• At least one medically eligible person over 60 years of age.
• An APD companion case with no medically eligible children. (For example: OSIPM husband and OHP-OPU wife)

In general, 5503 carries medical cases in which there is:

• No medically eligible person over 60 years of age
• No SS companion case (either SNAP or medical)
• No APD companion case (exception: a case with medically eligible children AND no medically eligible individual who is 60 or over, such as a caretaker relative).

For more information on which cases SSP branch offices carry, please see SPD WG B-4.

• Note: If an APD client contacts branch 5503 with an address change, 5503 will email the information to the appropriate local office. It will be the responsibility of the local office to make the necessary changes to CMS and SNAP.

Example 1:
An application is received at 5503 with a 60+ medically eligible adult and a medically eligible child. 5503 will review the case for TANF related medical for all applicants. If the adult and child are eligible for TANF related medical together (MAA, MAF) 5503 will keep the case and narrate in TRACS.
Example 2:
An application is received at 5503 for a 60+ medically eligible adult and a medically eligible child. 5503 will review the case for TANF related medical for all applicants. If there is no TANF related medical, 5503 will process medical for all household members and transfer the case to the local APD/AAA office. for further any additional services.
Example 3:
An application is received at 5503 for a non eligible 60+ adult and a medically eligible child. 5503 will process the medical for the child and hold the case in their branch.
Example 4:
An application is received at 5503 for a non eligible 60+ adult and a child eligible for Healthy Kids Connect coverage only. 5503 will process the HKC medical for the child and hold the case in their branch.
Example 5:
An application is received at 5503 for a 60+ medically eligible adult and a child eligible for Healthy Kids Connect coverage only. 5503 will process the HKC medical for the child and hold the child’s HKC case in their branch. 5503 will process the medical request for the adult as far as they can s and transfer the case to the local APD/AAA office for further any additional services.

Age 60+ agreement between 5503 and APD/AAA offices

Currently in effect for 60+ applicants not on the SRL as well as 60+ applicants selected from the SRL.

5503 will:

• Screen the application to determine if a 60+ person is part of the filing group and requesting medical. All applications will be transferred when appropriate, including those who have been selected from the Standard Reservation List (SRL).
• If a 60+ applicant, is requesting medical and is the only person on the application, 5503 will transfer the application to the local APD/AAA office without processing.
• If a 60+ applicant is requesting medical with another adult who is not 60+, 5503 will transfer the application to the local APD/AAA office.
• If a 60+ applicant is requesting medical with children, the application will be processed to completion at 5503 and then transferred to the local APD/AAA office.
• Applications for mixed households will be transferred to the local APD/AAA office without processing if there is an open companion case in the local office.
• The local APD/AAA office should review the transferred application for potential service benefits.
• MAA/MAF cases will not be transferred to the local APD/AAA office; 5503 will hold the case.
• Healthy Kids Connect cases will not be transferred to the local APD/AA office; 5503 is required to hold all HKC cases. For more information on makig HKC decisions, see the HKC flowchart
• If a recertification is due the next month OR a DHS945 has been received, 5503 will not transfer the application until after the eligibility has been determined.
• If applicant has been selected from the SRL, 5503 will code LST for all adults in the filing group. If needed, set up a case and place in pending status at the APD/AAA office. Reservation list database will be updated.
• If each adult has a separate LST number and both are selected, both adults will be coded LST with their individual numbers.
• Race and Ethnicity will be updated for all persons sharing the LST number and/or all persons who have been selected.
• If another adult(s) is sharing the same LST number, the additional adult(s) will be added to the database as person 2 and/or 3.
• Add a TRACS entry including date of request, date application was received, client name, LST number and APD/AAA contact.
• Send an email to the appropriate APD/AAA office using the case transfer email adress in Outlook with the TRACS narrative in body of email and an attached PDF file with the application and supporting documents.

APD/AAA will:

• Determine if eligible for any Medicaid programs.
• Update the SRL database with changes to client information, application status and final eligibility decision.

EPD agreement between 5503 and SPD/AAA offices

PMDDT agreement between 5503 and APD/AAA offices

Currently in effect for applicants over age 18 claiming a disability who are not receiving SSD or SSI income and/or not already receiving “plus” benefits.

5503 will:

• Refer the application to the appropriate local APD/AAA office if:
• The applicant marks YES to question number 11 on the 7210 or 7210R AND marks YES to question 3 on the 7214;
• Or marks YES to question 2 on page 7 of a 415F;
• Or marks YES to question 11 AND marks YES on part D of the question on the 7210W.
• Note: If the individual or child claiming the disability is already receiving “plus” benefits, the case will not be referred.

• If the applicant has been selected from the SRL, 5503 will code LST for all adults in the filing group. If needed, set up a case and place in pending status at the APD/AAA office. The Reservation list database will then be updated.
  • If each adult has a separate LST number and both adults are selected, both will be coded LST with their individual numbers.
  • Race and Ethnicity will be updated for all persons sharing the LST number and/or all persons who have been selected.
  • If another adult(s) is sharing the same LST number, the additional adult(s) will be added to the database as person 2 and/or 3.
• Add a TRACS entry including date of request, date application was received, client name, LST number and APD/AAA contact.
• Send an email to the appropriate APD/AAA office using the case transfer email address in Outlook with the TRACS narrative in body of email, and an attached PDF file with the application and supporting documents.

APD/AAA will:

• Determine eligibility for PMDDT and all other APD Medicaid programs if not eligible for PMDDT.
• APD/AAA will update the SRL database with changes to client information, application status and final eligibility decision.
  

If 5503 Transfers Case to Local APD/AAA Office

Local contact person:

• Receives email and supporting documents from 5503
• Narrates the case was received and notes to whom the case has been assigned.
  
  
• Note: If the medical referral is directed to an incorrect APD/AAA local office, the local contact person will narrate in ACCESS and forward the referral to the correct local contact person. The UCMS and Oregon ACCESS case will be transferred online to the appropriate branch. A new GSOSIPR notice will be sent to the client showing the correct branch information.

Local Office Eligibility Worker:

• Screens application for OSIPM financial and nonfinancial eligibility factors.
  
  
• Note: Working client's with disabilities may be eligible for OSIPM and other programs, such as EPD.
  
  
• If ineligible for all Medicaid programs, the application process is complete and the eligibility decision is narrated on Oregon ACCESS and integrated to CMS. UCMS is updated with a PMD case descriptor. Denial notice is sent via the SDS 540. Keep a copy of the SDS 540 in the record.
  • The eligibility worker also adds the eligibility decision to the SRL database and updates client information if the applicant was selected from the SRL.
• If potential eligibility exists, based on age or disability for a non OHP Medical benefit, contact the applicant by phone or mail to schedule intake according to local procedures.
  • If the applicant is eligible for OHP-OPU only, process the application based on the information available on the mainframe and on the application. OHP applicants and clients cannot be pended for an interview.
  • If needed, the eligibility worker can call the OHP applicant for clarification or send a pending notice.
• If the non OHP applicant does not respond to outreach, or does not attend a scheduled intake appointment within 90 days of the date of request for Medicaid or within 45 days from the date the local office initiates contact (whichever date is later), update UCMS with a PMD case descriptor, narrate in Oregon ACCESS and integrate with UCMS. Denial notice is sent via SDS 540. Keep a copy of the SDS 540 in the record.
  • The eligibility worker also adds the eligibility decision to the SRL database and updates client information if the applicant was selected from the SRL.
• If the applicant completes the intake process, and a PMDDT referral is necessary, obtain information about medical providers. Complete a release of information (DHS 2099) for each medical provider and one for SSA. Complete forms SDS 0620 and SDS 0708.
• Create P2 Pending case with PMP and ADM case descriptors if the client is not already on OHP Standard.
• Refer case to PMDDT for disability determination as per local office procedures.

If PMDDT case is approved:

• Convert case from program P2 to _5, with PMA and OSP case descriptors. complete OHP Standard premium refund process if client is eligible for refund. (via OHP 7204)

If PMDDT case is denied:

• Issue denial notice (via SDS 540).
• Narrate in Oregon ACCESS.
• Remove PMP on UCMS and replace with PMD.
• If there is an active OHP-OPU case and no SPD companion case, transfer CMS case back to branch 5503.

PMDDT Process:

• Receives referral from local APD/AAA office.
• Obtains needed information from medical providers to determine disability (unless otherwise provided).
• Notifies referring worker of decision within 90 days.
• Narrates actions and decision in Oregon ACCESS or TRACS.
  
  
• Note: Presumptive Hearing requests will be handled by APD Hearing Representatives
• Note: OHP Standard denial hearing requests will be handled by branch 5503

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 Management (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)