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Staff tools | MSP Manual | C. Eligibility
Groups
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DHS home | APD
Staff tools | MSP Manual | C. Eligibility
Groups
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This section explains rules which determine how individuals are filtered into each of the five eligibility groups. They are:
The ONE System will determine the EDGs through the rules engine in the background. However, it is important to understand how EDGs are formed to recognize how the eligibility determination is affected in order to accurately authorize benefits and be able to explain results to individuals. This section tells you how many people in the household are in each eligibility group. This determines whose money is counted, which income and resource standards are used and who is eligibile to receive MSP benefits.
The household group consists of 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. The people in the household group who apply for benefits are called applicants.
Note: Applying for or receiving services has no effect on Medicare Savings Program eligibility groups whatsoever, it's all about who lives with whom.
A separate household group is established for people who live in the same dwelling as another household group, if a landlord/tenant relationship exists.
People who live with more than one household group during a calendar month are members of the household group where they spend 51 percent or more of their time.
People gone from the household for 30 days or more are no longer part of the household, this includes individuals who enter an acute care hospital or nursing facility and are expected to remain for 30 days or more. Leave the individual in their original household group until the 31st day, and then rerun eligibility as a household of one.
If a new applicant is or will be absent from the household becausethey are in the hospital or a nursing facility, then we can consider them in their own household group prior to the 30 days if we are going to be evaluating them for OSIPM under the Acute Care Setting (ACS) rule (OAR 461-145-0745) or long-term-care/services rule (OAR 461-145-0750). If the stay is not expected to last 30 days and the individual does not anticipate applying for services, evaluate the individual as if they were living at home. If an individual has not been discharged home by the 31st day, reevaluate them as a household of one.
Note: Notice that the MSP HH group for nonstandard living arrangements is different from that of OSIPM. If you have an individual who is in the same building as their spouse, even if they are receiving services, they are in the same HH group as their spouse for MSPs. They would be in separate HH groups for OSIPM. See OPEN chapter 8 for examples of nonstandard living situations.
Household Group; 461-110-0210
The filing group consists of the people from the household group whose circumstances are considered in the eligibility determination process. You cannot add people at this point (or at any other). If someone isn't in the household group, they will never be in the filing group.
If the filing group does not include at least one applicant who meets all nonfinancial eligibility requirements, the group is ineligible. Individuals must provide information requested by the department to determine who must be in the filing group.
When a household member is in more than one filing group for the same program, the filing groups must be combined, unless specified otherwise in administrative rule.
The filing group consists of each applicant and the following household group members:
Filing Group Overview; 461-110-0310
Filing Group; 461-110-0410
All the members of the filing group are also members of the financial group. The financial group determines whose income counts in determining eligibility for benefits.
Financial Group; 461-110-0530
The need group consists of the people whose basic and special needs are used in determining eligibility and benefit level. The need group consists of each member of the financial group. Think of the need group as the "income standard group" - the number of individuals in the need group determines what income standard you will use (1-person, 2-person, etc.). Some need group members may not be in the benefit group.
Need Group; 461-110-0630
The benefit group consists of the people who receive benefits.
For individuals who are not assumed eligible, the benefit group consists of the people from the need group who meet all nonfinancial and financial eligibility requirements.
For individuals who are assumed eligible, the benefit group consists of the people who are in the benefit group of the program used to assume eligibility.
Benefit Group; 461-110-0750
