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Medicare Savings Programs and Medicare Buy-In

B. Medicare Savings Programs (MSP) Application

Effective 5/7/21

1. Application Process Overview

Individuals wishing to apply for Medicaid may:  

• Complete the OHP 7210 + Appendix A paper application, or
• Use the ONE Applicant Portal at  https://one.oregon.gov/, or
• Call OHA at 1-800-699-9075, or
• Visit a local ODHS office.

Local offices must ensure that application forms are accessible to anyone requesting them and that federal and state eligibility requirements are accurately applied within the applicable time frames.

Local offices are also required to assist individuals in completing the application process. This may include helping individuals complete the application or gather the information necessary to determine eligibility.

If eligibility cannot be determined during the intake interview, the individual must be given or mailed a written notice that outlines the information needed to determine eligibility, the eligibility requirements for the specific MSP and the amount of time the individual will have to provide that information. ONE will send a request for information (RFI) when workers indicate verification is needed.

Manual Notices  

If sending a manual notice, the due date listed on the DHS 0210 should be 30 days from the date the pending notice is mailed or provided.  The worker should only allow more than 10 days if circumstances require more time (e.g. individual must send away for a birth certificate); however, the deadline should allow sufficient time to complete the eligibility determination before the 45th day (unless there is good cause to extend beyond the 45th day). If possible, communicate to the individual the importance of returning the information as soon as possible to allow time for processing.  Remember that the deadline can be extended for good cause (see OAR 461-115-0190). Note: If the deadline on the 210 falls on a weekend or holiday, use the next working day.

Address

Although individuals 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 a branch address. To use a branch address means the Department is sending the participant notice to the Department and not the individual. For those experiencing homelessness, the mailing address may be General Delivery or the address of a shelter or a friend.

There is a company, Change HealthCare (formerly Altegra), who may be involved with applications for individuals who are recipients of an HMO who has contracted with Change HealthCare to do this outreach work. They have approval from the Centers of Medicare and Medicaid Services to undertake this work, which is important as it may impact individuals who do not know about MSPs and assistance with Medicare costs. Change HealthCare’s eligibility workers are centered in Florida and act as the applicant’s authorized rep. They gather the application, 231, and verification and send it directly to the ONE Customer Service Center for processing. They will also include a response form, which should be sent back to them with the result of the eligibility decision (approval/denial and the reason). Treat these applications in the same manner as any other application, being sure to include Change HealthCare as the Authorized Rep in ONE so that they are included on any correspondence. There may be confusion because the individual calls and wants to know if the contact is legitimate. The easiest thing to do is ask them if the contact is from Change HealthCare or a person from Florida. They may choose not to have Change HealthCare as their Authorized Rep and want to work only with ODHS|OHA instead and that is OK.

• Note: Sometime during the year, usually in early spring, the Social Security Administration sends letters out to individuals they think may be potentially eligible for Medicare Savings Programs (QMB, SMB, SMF).  Staff may receive calls and/or applications for the Medicare Savings Programs from individuals referring to these letters.  They may well be over income as SSA doesn’t have complete data.   

All signed applications should have a corresponding ONE case. If the individual does not have an open ONE case after signing and submitting an application, create a new one or reopen a closed case (if applicable) by selecting the Add/Reapply Program option.

Application Process; 461-115-0010

2. Date of Request

The date the individual or someone acting on their behalf contacts the Department with a request for benefits is considered the date of request. The contact may be by phone, an office visit, or written. Use the date of request to establish the date for starting the application process and the date from which the effective date is determined.

Date of Request; 461-115-0030

3. Application Requirements

In order to receive a full eligibility decision, the applicant or their authorized representative must do all the following:

• Complete an application;
• Cooperate in providing necessary information and verification within the time frames specified; and
• Meet the interview requirements of rule 461-115-0230

Application Requirements; 461-115-0020

4. When an Application is Required

A new application is required when applying for MSP benefits for the first time (with some exceptions, see below) or when there’s a break in aid.

A new application is not required under the following circumstances:

• When a single application can be used for both a denial in the month of application and for determining eligibility the next month if anticipated changes for the next month are within the processing time frame.
• When a case is closed and reopened in the same month.
• When a case is suspended for one month because the case was over income, and the case is reopened the month after the suspended month.
• When medical benefits are suspended because an individual was incarcerated, they were released, and the individual contacts the Department within 10 days of their release (See the Special Considerations for Incarcerated Clients worker guide).
• The individual was receiving OSIPM or MSP benefits; was terminated for failure to provide requested information during a periodic redetermination; and the requested information was received within 90 days of the termination (see OAR 461-115-0430)

When to Use an Application: 461-115-0050

5. Who Must Sign the Application and Complete the Application Process

The application processcan be initiated by one of the following:

• Any member of the filing group, 18 years of age or older
• The authorized representative
• For someone who is incapacitated, or for a child under 18 who has no parent or legal guardian to apply, we can accept an application signed by anyone 18 or older acting responsibility on the person’s behalf.
• Incapacity:  Prior to 5/15/20, DHS could designate an authorized representative on someone’s behalf if we determined that the person was physically or mentally incapacitated and unable to apply for themselves, needed an authorized representative, and did not have someone with the legal authority to act for them or designate another authorized representative.  Use the same criteria to determine whether someone is incapacitated under the new rule that was used to determine whether someone needed an authorized representative designated by DHS under the previous rules.
• Acting responsibly: Use the same criteria to determine whether someone is acting responsibly to apply for someone under the new rules that was used to decide if someone was appropriate for DHS to designate as the authorized representative under the old rules.

If a person who must sign the paper application is unable to write their name, they may sign with their mark. The mark must be witnessed by an employee of the local office.

Who Must Sign the Application/Complete the Application Process; 461-115-0071

6. Authorized Representatives

An Authorized Representative (AR) may be used to act on behalf of the applicant or filing group to complete the application process, report changes, obtain benefits, or use benefits (for APD, the latter generally applies to SNAP and Special Needs). When possible, the individual or spouse should review any information provided by an AR. The filing group is responsible for any information given by their AR; however, the AR is also liable for any overpayment resulting from the AR knowingly giving incorrect or incomplete information or intentionally withholding information.

IMPORTANT: The role of AR is limited to programs that require a financial eligibility determination, such as OSIPM, SNAP, REF(M), TANF, etc.  There is no AR for long-term services and supports. 

As of 3/1/19, individuals can only have one AR for all benefits they receive from ODHS (except TA-DVS).

• Example: Betty can’t have homecare worker Dawn as the AR for SNAP and daughter Jennifer as the AR for OSIPM.  Betty must choose either Dawn or Jennifer to be the AR for both OSIPM and SNAP.
• An MSC 0231 must be completed by both parties and uploaded to the ONE electronic file as it contains the information regarding the AR's liability.
• The MSC 0231 is valid until revoked by the individual, the AR, or the AP, either verbally or in writing. If it is revoked, it should be marked void and a new MSC 0231 must be completed if the individual reconsiders at a later date.
• A Power of Attorney (POA) agreement or guardianship does not suffice for AR status - the MSC 0231 must still be completed by the individual and the AR because of the overpayment liability language. Again, the overpayment liability language on the MSC 0231 is the reason it is required in situations where others may typically have authority to act for the individual. If the applicant is mentally incapacitated and unable to designate someone on their own behalf, then the person with POA or guardianship can appoint themselves and complete both sections.
• Despite the information above, a legal guardian or individual with POA can designate a third party as the AR or AP.  In that case, the guardian/person with POA completes the applicant portion, and the designated individual completes the AR and/or AP section(s).
• A natural or adoptive parent of a child under age 18 does not need to be designated as the AR or AP on the 231, it’s understood that the parent has the sole authority to act on the child’s behalf.

Important: Simply adding the individual to the 7210 and having him/her sign also does not replace the need for an MSC 0231 because there is no information about the AR's potential overpayment liability on the 539A.

Important: The local office may no longer appoint an AR on someone’s behalf if they cannot apply for themselves, but the same person that we may have previously appointed as the AR can now complete the application process without the need to be appointed as the AR (see section B.5 above).

For an individual to act as a representative in a individual's care plan, see 411-030-0020. For in-home services, use the SDS 737.

Forms and Other Resources

Authorized Representatives and Alternate Payees Quick Reference Guide

Authorized Representatives;  461-115-0090

7. Offices Where Individuals Apply

Individuals can apply for Medicare Savings Programs at any ODHS or AAA branch office.  See the section B.1 above for more ways individuals can apply. 

Note:  Individuals who apply with the Social Security Administration (SSA) for extra help with their Medicare Part D costs (Low Income Subsidy or LIS) will be referred to the Department for evaluation of MSP eligibility.  These requests are considered requests for MSP benefits and should be acted upon.  The ONE system generates a daily report of individuals newly referred from the SSA.

Offices Where Clients Apply; 461-115-0150

8. Application Processing Time Frames

Determine eligibility within 45 days from the date of request for benefits. The limit may be extended for any of the following reasons:

• Information needed to determine eligibility is expected to be received after the 45-day limit, and the individual has no control over delivery; or
• Other circumstances exist that are not within the control of the individual or the local office, and this delays the eligibility decision past the 45-day limit.

Application Processing Time Frames; 461-115-0190

9. Application Withdrawal

Individuals may withdraw their application at any time during the application process.

• Note: If a signed application is received, a basic decision must be sent, even if the individual withdraws the application in writing or orally. If the applicant completes a 457D, no additional notice is required. No notice is required if a signed application is not recieved.

461-115-0010

10. Interviews

An interview must be conducted to gather information needed to determine eligibility at initial application for all MSP applicants (see exception below for current OSIPM recipients). No interview is required at redetermination. The same individuals who can complete the application process can also complete the interview.

Effective 7/6/20, when someone is currently receiving OSIPM benefits and wants to apply for MSP benefits, an interview is not required if the individual completed an interview in the current OSIPM determination or renewal period and there has been no break in aid (i.e. within the last 12 months).

Note: SSI recipients who are assumed eligible for QMB are still required to complete an interview at initial application.

461-115-0230

11. Verification

Verification is required for all eligibility requirements, including identity, at the initial application, when changes occur and if information is questionable. The acceptable methods of verification are listed below:

• Electronic - information available and provided to the Department from an electronic source, such as SSA screens, WAGE, WVIR, OVERS, MMIS, ECLM, HINQ, Secretary of State website for incorporated businesses, county Tax Assessor's or incarceration websites, etc.
• Self-attestation - information provided orally or in writing (such as on the application) by or behalf of the individual
• Documentation - documentary evidence, such as bank statements, award letters, trust documents, etc. This includes documents viewed (but not copied or physically retained) during a home visit.

We should not request documentation if we can verify the information electronically, or if the rules allow for self-attestation. Below are the verification guidelines for each category:

Citizen/Non-Citizen Status

• Anyone who self-attests to be a U.S. citizen does not have to provide verification if they meet one of the following requirements:
  • The individual receives SSI
  • The individual is entitled to or is enrolled in any type of Medicare
  • The individual is receiving SSDI
  • The individual is receiving foster care assistance
  • The individual is a newborn of someone receiving SSI or in 1619b status
• Otherwise, see APD B.1 (#2 Citizenship and #3 Alien/Noncitizen Status) and OAR 461-115-0704
• After initial application, citizen/noncitizen status does not have to be verified again unless a change has been reported or the individual's status becomes questionable.

Financial Eligibility

• Electronic verification should be utilized first. We should request documentation only if one of the following applies:
  • The information is not available to the Department electronically; or
  • The information is available electronically and:
    • For non-service individuals, information provided by self-attestation is different than the information available to the Department electronically, and neither the individual nor anyone acting on the individual's behalf can give a reasonable explanation as to why
  • For service recipients, the self-attested info is different than what is available electronically (regardless of an explanation)

Identity

• The Applicant Portal in ONE incorporates a Remote Identity Program check whenever individuals attempt to create a new Applicant Portal account or apply for benefits for the first time.  See the Remote Identity Proofing (RIPD) Quick Reference Guide for more information.
• We can accept verification of identity from a federal agency or another state agency (such as Self Sufficiency or another APD/AAA branch) if they verified and certified the identity of the individual for the following purposes:
  • Public assistance
  • Law enforcement
  • Tax filing or other Internal Revenue Service or tax bureau business
  • Corrections
• Using WVIR and SSA screens to verify identity is acceptable as long as it is done properly. In other words, there should be some quizzing involved during which the worker asks the applicant specific questions, rather than listing the info and simply saying, “Is that correct?” 
• WVIR screens: Ask about identifying information visible on their DL display screen (license #, license type, issue date, expiration date, height, weight, etc.) or the vehicle list screen.
• SSA screens: Ask about SSB, SSI, or Medicare start date, disability dates, address on record with SSA, alternate payee info (if any).
• If we cannot verify from another agency, the Department must accept the following as proof of identity, provided such document has a photograph or other identifying information sufficient to establish identity, such as name, age, race, height, weight, eye color, or address:
  • Driver's license issued by a State or Territory
  • School identification card
  • U.S. military card of draft record
  • ID card issued by federal, state, or local government
  • Military dependent ID card
  • U.S. Coast Guard Merchant Mariner card
  • For children under age 19, a clinic, hospital, or school record, including preschool or day care records
  • Two other documents with consistent information that corroborates identity, such as:
    • Employer ID cards
    • High school, high school equivalency, and college diplomas
    • Marriage certificates
    • Divorce decrees
    • Property deeds or title
• If the individual does not have any of the documents listed above, and identity can't be identified using the information from another federal or state agency, we must accept an affidavit signed under penalty of perjury by someone other than the individual who can reasonably attest to the applicant's identity. Such affidavit must contain the individual's name and other identifying information, such as name, age, race, height, weight, eye color, or address

Social Security Numbers

We must verify that the SSN an individual provides belongs that person. Acceptable sources of verification must show the correct SSN. The following is not an exhaustive list of acceptable items:

• Social Security Card
• SSA award letters or other SSA correspondence bearing the individual's SSN
• Medicare card, if the individual is receiving Medicare off his/her own record (until the new cards are issued without the SSN)
• Electronic SSA interfaces (BEIN, TPQY, MMIS TBQ)
• Wage stubs or other employment/unemployment records
• IRS forms or letters

Pregnancy- The Department must accept self-attestation of pregnancy unless the Department has information that is not reasonably compatible with the individual's statement, in which case we can require verification from a doctor's office or clinic.

Residency, age, DOB, household size - The Department must accept self-attestation of these factors unless the Department has information available (electronically or otherwise) that differs, in which case we can require the individual to provide documentation.

Other Important Information to Remember About Verification

• On a case-by-case basis, if information is not available electronically or from a third party, the Department may accept self-attestation to verify all eligibility factors above (except citizenship and immigration status) under the following circumstances:
  • Documentation does not exist at initial application or at redetermination; or
  • Documentation is not reasonably available at initial application or at redetermination, such as in the case of homelessness, domestic violence, or natural disaster
• The Department cannot deny, close, or reduce benefits if verification isn't available to the Department, or if the available information is incompatible with information the individual provided if the Department did not request additional information from the individual.
• Verification provided for one program is used as verification for all programs in which the individual participates.
• See OPEN chapter 3, section 2 for more information on verifying information.
• The terminology may have changed in rule, but keep in mind that reasonably compatible means the information is not questionable. Note: This is not the same thing as reasonable compatibility in the MAGI program. Information is considered questionable if it is inconsistent with any of the following:
  • Other reported information
  • Other information provided on the application or previous applications
  • Other information received by the branch office (electronically or otherwise
• Use an MSC 3010 signed and dated by the individual that specifies the institution or person from which the information is to be obtained.
• When acceptable verification is not provided, deny the application or end ongoing benefits.
• Verification of the occurrence of an act of domestic violence is not required for any program.
• Self-attestation can be accepted as verification of Native American tribal status.

Verification; 461-115-0610

Required Verification; 461-115-0700

Required Verification of Citizenship and Alien Status; 461-115-0704

12. Notices

Approval notice. Approval, denial, reduction and closure notices (Notice of Eligibility or NOE) are automatically generated when benefits are approved and authorized in ONE.

Each notice will include the hearing rights on the second page. Spanish, Russian and Vietnamese versions are also automatically generated.

13. Case Documentation

General Rule:  While most eligibility factors can be verified by viewing documents and narrating, it is preferable to make electronic file copies whenever reasonably feasible.

Verify Lawful Presence (VLP) interfaces with the Department of Homeland Security to verify an individual’s non-citizen status details. The Social Security Administration (SSA) has a contract with the ODHS called a Computer Matching/Data Exchange Agreement. ODHS is also able to access other Income Eligibility and Verification System (IEVS) screens.

Use the following guidelines when verifying and documenting eligibility factors in the case file:

• If citizenship documentation is required (i.e. VLP is not able to verify) a copy of the documentation must be in the electronic case file.
• A copy of non-citizen status documentation (not SAVE) must be in the electronic case file when verification through VLP or state/federal data systems is not available, except for individuals receiving CAWEM benefits.
• Self-attestation of residency is acceptable unless questionable. 
• SSA records should be used to verify SSN whenever possible
• For IEVS required checks add a case note to indicate that “All appropriate IEVS screens checked”.  Document in a case note any eligibility information that was found:
• If the reported information does not match IEVS, add a case not to explain how the discrepancy was resolved.  Example:  ECLM shows $250 UC, applicant reports $225, applicant provided written verification (in file) of $225 UC.
• If the information was unreported, add a case not to explain how the discrepancy was resolved.  Example:  ECLM shows $250 UC – unreported.  Applicant confirms receipt of benefit via phone call.
• Copies of documentation used to verify OHI should be in the electronic case file when possible (e.g. copy machine available).
• Forms signed by the individual should be kept in the electronic case file.  Forms provided to the individual should be documented in a case note.

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.

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