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Staff Tools | QMB Program Manual | F. Issuing Benefits
and Changes
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DHS home | APD
Staff Tools | QMB Program Manual | F. Issuing Benefits
and Changes
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For changes that are required to be reported, clients may report by telephone, office visit, report form, or other written notice. Clients are required to report within 10 days all changes in income, resources, or circumstances that may affect their eligibility for benefits or the amount of benefits they receive. They must report within the following time frames:
Changes are considered reported effective the date the information is received by the Department.
Changes reported for one program are considered reported for all programs in which the client participates, and should be acted on according to the requirements of each program.
For more information on reporting changes, go to Generic
Program Elements E.
Changes Required to Report: 461-170-0011
Reporting Time Frames: 461-170-0010
Late, Incomplete or Nonreporting. If the Department discovers that a client failed to report changes they are required to report and, as a result, the benefit group received benefits they were not entitled to, the Department must file an overpayment against the financial group.
For more information on overpayments, go to Generic Program Elements G.
If a reported change results in insufficient information to determine how the change will affect eligibility, the Department may require a new application.
Failure to Report: 461-170-0040
Acting on Reported Changes. When a client makes a timely report of a change that could reduce or end medical benefits, the Department must review each individual in the filing group for other medical program eligibility prior to reducing or ending medical benefits.If additional information is needed to act on the timely reported change, members of the benefit group remain eligible from the date the change was reported until the Department determines their eligibility in accordance with the application processing time frames.
QMB benefits are issued by providing the client with a medical card. Clients that receive SMB and SMF only do not receive a medical card.
See QMB B.12 for information on issuing notices.
For more information on issuing benefits, go to Generic Program Elements C.3 through C.13
Authorizing Benefits: 461-165-0020
The effective date is the day that action will be taken or a change made on a case. When a change cannot be made by the effective date, make the change as soon as possible and supplement benefits or write an overpayment as appropriate. Dates must be easily identifiable in all cases.
Initial Month Medical Benefits. For all Medicare Savings Programs, the effective date is always the first of a month.
The effective date for starting benefits for QMB is the first of the month after the benefit group has been determined to meet all QMB eligibility criteria and the Department receives the required verification.
For example, a client tells us in March they will start receiving Medicare in April. They would not be eligible for QMB until May 1st. This is because they don’t meet QMB criteria until they begin receiving Medicare. They receive it in April, so they start QMB the month after (May).
The effective date for starting medical benefits for SMB and SMF is determined as follows:
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The effective date for starting medical benefits for DW is one of the following, whichever occurs first:
Adding a New Person to an Open Case. For QMB and DW the effective date for adding a new person to the benefit group is the first of the month after the new person has been determined to meet all eligibility criteria and the Department receives the required verification.
For SMB and SMF, the first of the month in which the new person has been determined to meet all eligibility criteria and the Department receives the required verification.
Removing a Person. If the person has left the benefit group in the current budget month because they are ineligible, disqualified or left the household, the effective date is:
If the person is reasonably expected to leave the household next month, the effective date is the later of the following:
Redetermination. The effective date for continuing eligibility at the end of the redetermination period is one of the following:
Closing/Suspending Benefits. The effective date for ending benefits when the only elgibible person on the case dies is the date of death.
When using prospective budgeting, the effective date for closing or suspending benefits is the last day of the month in which the notice period ends.
When using retrospective eligibility or budgeting, the effective date for closing or suspending benefits is the end of the budget month.
| Suspending Benefits for incarcerated clients: The effecive date for suspending benefits for a client who receives medical assistance and become incarcerated is the effective date on the decision notice. |
Denial of Benefits. The effective date for denying benefits is the earliest of the following:
Restored Benefits. The effective date for restoring benefits that were underpaid (including erroneous collections of overpayments), or denied or closed in error is one of the following:
Redetermination is the process used to review eligibility to approve or deny continuing benefits. The redetermination is the period between initial eligibility and the point in time when eligibility is reviewed.
The redetermination process includes an interview, completion of the Oregon ACCESS tabs and narration and any required verification. Clients must cooperate in the eligibility redetermination or their benefits are closed. A signed application is not required during a periodic redetermination or anytime eligibility is redetermined due to reported changes. See SPD WG B.8 for more information.
For clients who are not eligible for SSI, complete a redetermination once every 12 months. For clients who are eligible for OSIPM or FS, complete the QMB redetermination when the other program’s redetermination is due.
For clients who have SSI, verify the receipt of SSI every 12 months.
Refer to SPD WG B.8 for more information on the process of redetermination.
Effective Dates. When a redetermination of eligibility is initiated, the Department must review each individual in the filing group for other medical program eligibility prior to reducing or ending medical benefits. If additional information is needed to redetermine eligibility, members of the benefit group benefit group remain eligible from the date the review is initiated until the Department determines their eligibility in accordance with the application processing time frames.
