QMB D. Nonfinancial requirements

DHS home | APD Staff tools | QMB Program Manual | D. Nonfinancial requirements

QMB Program Manual

D. Nonfinancial Requirements

Effective 7/1/10

1. Residency

To be eligible for benefits a person must be a resident of Oregon. People are residents if they live in Oregon. There is no minimum amount of time a person must live in Oregon to be a resident; however, they must intend to remain in Oregon.

Residency does not require a permanent dwelling or a fixed mailing address.

People are not residents if they are in Oregon solely for vacations.

People continue to be residents during temporary periods of absence if they intend to return when the purpose of the absence is completed.

461-120-0010

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:

An individual age 21 or older who is capable of indicating intent to reside is considered to be a resident of the state where the individual is living with the intention to remain permanently or for an indefinite period.
An individual age 21 or older who became incapable of indicating intent to reside after age 21 is considered to be a resident of the state where the facility is located unless the individual was placed in the facility by a state agency of another state. When a state agency of another state places an individual, the individual is considered to be a resident of the state that makes the placement.
For an individual under age 21 who is incapable of forming an intent to reside, or an individual of any age who became incapable of forming that intent before age 21, the state of residence is one of the following:
- The state of residence of the individual's parent or legal guardian at the time of application.
- The state of residence of the party who applies for benefits on the individual's behalf, if there is no living parent, or the location of the parent is unknown, and there is no legal guardian.
- Oregon, if the individual has been receiving medical assistance in Oregon continuously since November 1, 1981, or is from a state with which Oregon has an interstate agreement that waives the residency requirement.

461-120-0030

Incapable of Stating Intent to Reside. A person is considered incapable of stating intent to reside if any of the following is true:

The person's IQ is 49 or less.
The person has a mental age of 7 or less as determined by tests used to establish IQ.
The person is judged legally incompetent by a court of law.
Other acceptable medical documentation supports a finding that the person is not capable of indicating intent. Acceptable sources are a physician, a psychiatrist or a psychologist.

461-120-0050

2. Social Security Number

To be included in the need group, a person must provide their SSN or apply for a number if they do not have one and provide the number when it is received.

An individual is not required to apply for or provide an SSN if the individual:

Is a member of religious sect or division of a religious sect that has continuously existed since December 31, 1950; and
Adheres to its tenets or teachings that prohibit applying for or using an SSN.

Note: The branch office must not deny, delay, or end benefits pending receipt of an SSN after a person has applied for a number with the SSA.

461-120-0210

3. Assignment of TPR and Support and Pursuing Assets

Medical Assignment. The Department has the authority to collect reimbursement for medical expenses the Department paid for anyone in the benefit group that should have been paid by another party or resource. By signing the application for assistance, clients agree to turn over any rights to health insurance or medical support to the Department. This is called assignment of medical benefits. The Department has the authority to refuse to pay medical expenses for anyone in the benefit group when another party or resource should pay first

The Department has the authority to collect medical reimbursements from the following sources:

Any medical support. This is medical coverage through an absent parent available under an order of a court or administrative agency.
Any third-party payments for medical care. This includes, but is not limited to:
- Any commercial insurance (including health or casualty) available through professional associations, unions fraternal groups, employer-employee benefit plans, or similar plans offering these payments or services, including self-insured and self-funded plans, or profit or non-profit prepaid plans offering either medical services or full or partial payment for services.
- A claim for damages from personal injuries.

The Department authority does not include collecting reimbursements from Medicare benefits.

The amount of the Department authority to collect reimbursement is equal to the full amount of medical services paid by the Department on the client's behalf.

461-120-0315

Requirement to Pursue Assets. To be eligible for benefits, the client must actively pursue any asset (except support and medical coverage) for which they have a legal right or claim, except as follows:

Clients applying for or receiving any program benefits from the Department are not required to apply for other programs administered by the Department (e.g., QMB clients are not required to apply for FS).
Individuals are not required to:
- Pursue loans.
- Pursue SSI.
- Make an effort to obtain any asset if the individual can show good cause for not doing so. Good cause means a circumstance beyond the ability of the individual to control.

To pursue available assets, the client must do all the following:

Apply for and satisfy all requirements to receive benefits from other programs.
Pursue legal remedies to obtain assets from any other source if they can secure legal counsel on a contingency fee basis.

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.

461-120-0330

Medical Cooperation. Medical coverage is the following:

Any medical support. This is medical coverage through an absent parent available under an order of a court or administrative agency.
Any third-party payments for medical care. This includes, but is not limited to:
- Any commercial insurance (including health or casualty) available through professional associations, unions, fraternal groups, employer-employee benefit plans, or similar plans offering these payments or services, including self-insured and self-funded plans, or profit or non-profit prepaid plans offering either medical services or full or partial payment for services.
- Coverage under Medicare (including Part D).
- A claim for damages from personal injuries.

To be eligible client must cooperate (unless good cause exists per 461-120-0350) in obtaining medical coverage under the following conditions:

Cooperation includes, but is not limited to, applying for, accepting and maintaining available resources and identifying and providing information to assist the Department in obtaining medical coverage.
The penalty for failure to cooperate with medical coverage is removing the person who refuses to cooperate from the need group.

End the noncooperation penalty for failure to cooperate with medical requirements when the client provides evidence that they are willing to cooperate.

461-120-0345

4. Age Requirement

To be eligible for QMB-BAS, QMB-SMB, QMB-SMF programs, a client may be any age.

To be eligible for the QMB-DW program, a client must be less than 65 years of age.

461-120-0510

5. Assumed Eligibility

Assumed eligibles are people who meet the eligibility requirements of a program based on other benefits they receive or are deemed to receive.

People who receive Part A of Medicare and SSI are assumed eligible for QMB-BAS.

461-135-0010

6. Specific Requirements

The following requirements apply to QMB-BAS:

To qualify for QMB-BAS, an individual must be receiving Medicare hospital insurance under Part A. This includes people who must pay a monthly premium to receive coverage.
Clients who qualify for QMB-BAS are not eligible to receive the full range of the Department's medical services. QMB-BAS benefits are limited to payments toward Medicare cost-sharing expenses. These expenses are:
- Medicare Part A and Part B premiums; AND
- Medicare Part A and Part B deductibles and coinsurance up to the Department's fee schedule.

The following requirements apply to QMB-DW:

To qualify for QMB-DW program, an individual must be eligible for Part A of Medicare as a qualified worker with a disability under Section 1818A of the Social Security Act. These are individuals under age 65 who have lost eligibility for Social Security disability benefits because they have become substantially gainfully employed, but can continue to receive Part A of Medicare by paying a premium.
QMB-DW clients are eligible only for payment of their premiums for Part A of Medicare. They may not have eligibility for any other medical assistance program and be eligible for QMB-DW.

The following requirements apply to QMB-SMB:

To qualify for QMB-SMB, an individual must be receiving Medicare hospital insurance under Part A. This includes individuals who must pay a monthly premium to receive coverage.
Clients who qualify for QMB-SMB are not eligible to receive the full range of the Department's medical services, they are eligible only for payment of the Part B premium.
Clients who qualify for QMB-SMB and whose income is between 101% and 120% of the federal poverty level

The following requirements apply to QMB-SMF (QI-1):

To qualify for QMB-SMF, a person must be receiving Medicare hospital insurance under Part A. This includes people who must pay a monthly premium to receive coverage.
Clients who qualify for QMB-SMF are not eligible to receive the full range of the Department's medical services. QMB-SMF benefits are limited to payment of Medicare Part B premiums.
Eligibility is limited to clients whose income is equal to or greater than 120% of the federal poverty level. Coverage is limited to payment of their Medicare Part B premium.
Clients who are institutionalized (reside in nursing facilities, ICF/MRs or hospitals) are not eligible for QMB-SMF.

461-135-0730

7. Retroactive Medical

QMB-BAS clients are not eligible for retroactive medical. However, if they are also eligible for OSIPM, they may be eligible for retroactive medical under that program.

If a benefit group currently eligible for QMB-DW requests and is eligible for retroactive medical benefits, the earliest date they can be eligible is three months before the effective date of their initial eligibility.

If a benefit group currently eligible for QMB-SMB or QMB-SMF requests and is eligible for retroactive payment of Part B Medicare premiums, the earliest date they can be eligible is three months before the effective date of their initial eligibility.Eligibility staff determine retroactive eligibility.

When a client is eligible for SMB or SMF retroactively, contact the buy-in unit at: MEDICARE@DHS.STATE.OR.US to have the system coded appropriately. Additionally, send a 148 to Client Maintenance Unit if the client is SMB or SMF only. A 148 does not need to be sent to CMU for dual eligible clients.

461-180-0140

8. Citizen/Noncitizen Status

To be a member of the benefit group a person must meet one of the following:

Be a citizen of the United States.
Be a qualified noncitizen and meet the alien status requirements per rule 461-120-0125.

461-120-0110

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:

SSI recipients.
Medicare recipients.
SSDI recipients.
Assumed eligible newborns born in Oregon. Once determined to be an assumed eligible newborn born July 1, 2006 or later, the client is exempt from providing citizenship documentation. A new system code to track Oregon born AENs has been requested.

Clients meet the noncitizen requirements if they meet any of the following:

Qualified non-citizen under age 19;
A non-citizen of a Compact of Free Association State who
has been admitted to the U.S. as a nonimmigrant, and is permitted by the Department of Homeland Security to reside permanently or indefinitely in the U.S;
Was a qualified non-citizen before August 22, 1996;
Physically entered the United States before August 22, 1996, and was continuously present in the United States between August 22, 1996 and the date qualified-noncitizen status was obtained. A person is not continuously present in the United States if he or she is absent from the United States for more than 30 consecutive days or for a total of more than 90 days;
Qualified non-citizens who have been in the qualified immigrant status for at least five years.
Are one of the following: a) are a veteran of the U.S. Armed Forces, who has honorably discharged not on account of alien status and who fulfills the minimum active-duty service requirement; b) are on active duty in the U.S. Armed Forces; or c) are the spouse or unmarried dependent child(ren) of an individual described in (a) or (b); OR
Receiving SSI and Medicare Part A.

Note: Documents provided to support alien status must be verified by INS. This verification requirement is known as the Systematic Alien Verification for Entitlements (SAVE) program. See Generic Program Worker Guide D.3 for more information on SAVE.

461-120-0125

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.