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Staff tools | MSP Manual | D. Nonfinancial
requirements
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DHS home | APD
Staff tools | MSP Manual | D. Nonfinancial
requirements
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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.
People are considered a resident if they have entered Oregon with a job commitment or are looking for work, as long as they are not receiving benefits from another state.
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.
Clients can still meet residency while “snowbirding” in Arizona or Southern California, for example, as long as the client plans on returning when the purpose (getting away from the Oregon winter) for their absence is completed. If it extends much beyond the winter months, it might be questionable whether residency is met. Also, if the client begins receiving benefits in Arizona or California, they are not eligible to receive benefits in Oregon. Workers and case managers should have a conversation with the client about benefits in the other state, particularly if this client was ever a service client, since there is a possibility that they require care just like they received in Oregon.
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:
Incapable of Stating Intent to Reside. A person is considered incapable of stating intent to reside if any of the following is true:
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:
Medical Assignment. The Department and the Oregon Health Authority (OHA) has the authority to collect reimbursement for medical expenses it paid for anyone receiving Medicaid (including OSIPM and MAGI) and REF(M) that should have been paid by another party or resource. This is called assignment of medical benefits. The Department and OHA has the authority to refuse to pay medical expenses for anyone receiving benefits when another party or resource should pay first.
The medical assignment process is a mandatory part of applying for and receiving medical benefits. By signing the application for assistance, individuals automatically agree to turn over any rights he or she has to health insurance or medical support to the Department/OHA, as well as the rights of anyone for which he/she is legally responsible who is receiving Medicaid or REF(M). The Department/OHA does not need the individual's express consent. This should be explained to applicants at initial application.
The amount for which Department has the authority to collect reimbursement is equal to the full amount of medical services paid by the Department or OHA on the client's behalf. See rule below for a list of whom the Department has the authority to collect medical reimbursements from.
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.
Cooperation in Identifying Liable Third Parties and Provide Other Information. The second piece to medical assignment, which requires more active participation, is cooperating with the Department in identifying third parties that are liable or potentially liable to pay for costs paid by the medical assistance program for anyone receiving medical assistance from the State of Oregon. The actual requirement to cooperate, however, only applies to the legally responsible individual, not a child who is not legally able to assign his or her own rights (for example). This means, if Dad applies for QMB and his son is receiving MAGI, and he refuses to cooperate in identifying the auto insurance company that is potentially liable to pay for his son's hospital bills (that MAGI already covered), then Dad is ineligible for QMB, the child does not lose eligibility for MAGI. We cannot penalize someone who is not legally responsible for himself/herself. Legally responsible individuals must also provide any other information that the Department, OHA, CCO, or PMCH needs in order to pursue payment from a liable third party.
Requirement to Pursue Assets. To be eligible for benefits, the client must actively pursue any asset for which they have a legal right or claim, except as follows:
To pursue available assets, the client must do all the following:
The penalty for not pursuing assets is that the individual is ineligible, not the entire benefit group. End the penalty when the individual provides evidence that they are willing to cooperate.
An individual is not required to make a good faith effort to obtain an asset if it will put the individual at further risk of current or future domestic violence.
Medical Cooperation. To be eligible for MSPs, legally responsible adult clients must:
Cooperation includes, but is not limited to, applying for, accepting and maintaining all 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 ineligibility for the legally responsible adult. A person can be penalized only if he or she has the legal right to obtain the health insurance, this means that individuals who cannot enroll in cost-effective employer-sponsored insurance for themselves are not disqualified. For example, if a spouse is unable to enroll on their own behalf, the spouse is not disqualified.
End the noncooperation penalty when the client provides evidence that they are willing to cooperate.
Good Cause for Failing to Pursue Health Care Coverage and Medical Support. Good cause includes the following:
Requirement to Obtain Health Insurance and Medical Support 461-120-0345
Good Cause 461-120-0350
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.
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 to meet the financial and citizen/non-citizen requirements for QMB-BAS. This means that the person will receive QMB-BAS for as long as they meet all the non-financial requirements. They still have to meet residency (OAR 461-120-0010) and pursuit of health care coverage and cash medical support requirements (OAR 461-120-0345).
The following requirements apply to QMB-BAS:
The following requirements apply to QMB-DW:
The following requirements apply to QMB-SMB:
The following requirements apply to QMB-SMF (QI-1):
Retroactive Medicare Savings Program benefits are only available for SMB and SMF. 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 (see the Effective Date section of the OSIPM manual). If eligible for OSIPM retroactively, the individual’s Part B premium will be paid with state general funds.
Retroactive medical may be requested at any time by the client, their authorized representative, or assumed from the applicant’s circumstances. A request for retroactive SMB or SMF benefits is assumed if the client incurred or paid the cost of their Medicare Part B Premium during the retro period, whether they indicate they had a cost on the application or not.
If a benefit group currently eligible for SMB or 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 original date of request. This means that there can potentially be a gap in coverage. For example, DOR is 9/30, effective date of SMB is 10/1 (verification of income was needed and not received until 10/5). The retroactive benefits cover June, July, and August (no benefits in September). An individual may be eligible in ANY one or ALL of the three months. To receive benefits, an individual must meet ALL eligibility factors for SMB or SMF other than pursuit of assets, which cannot be enforced until the applicant has been made aware of the requirement to pursue the asset.
Individuals are eligible for retroactive SMB and SMF even if they were not actually enrolled in Part B, BUT if that is the case, they must be eligible to enroll and must have incurred Medicare Part B covered services in those months. The person can be enrolled in Part B retroactively and SMB and SMF will pay the premium if the individual is eligible for SMB or SMF in each of the retroactive month(s). This includes deceased individuals who would have been eligible for Medicaid-covered premiums if a person acting on their behalf completes an application for them. Eligibility staff determine retroactive eligibility for SMB and SMF, it is no longer automatic.
Note: As of 1/1/17, individuals are not eligible for retroactive SMF in any month they were receiving OSIPM or MAGI, unless the retroactive period is prior to January 2017.
When a client is eligible for SMB or SMF retroactively, contact the buy-in unit at: BUY-IN.MEDICARE@DHS.STATE.OR.US to have the system coded appropriately. Additionally, send an Online CMU Request if the client is SMB or SMF only. Note: A CMU request is not needed to be sent for clients retroactively eligible for both OSIPM and SMB or QMB.
To be a member of the benefit group a person must meet one of the following:
Effective July 1, 2006 all Medicaid applicants are required to declare AND provide documentary evidence that they are US citizens or US nationals.
Applicants who state that they are US citizens AND who meet one of the following g are exempt from the requirement to provide documentary evidence:
Applicants who state that they are not US citizens or nationals are required to provide documentary evidence of their citizen/alien status, even if receiving any of the benefits listed above.
Applicants who are not receiving any of the benefits listed above are required to verify their citizenship using the methods and verification detailed in the APD Worker Guide, Section B.1.
After initial application, citizen/non-citizen status does not need to be verified again unless a change is reported or the individual's status becomes questionable.
Clients meet the noncitizen requirements if they meet any of the following:
