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Medicare Savings Programs Manual

F. Issuing Benefits and Changes

Updated 12/19/19

1. Processing Changes

Clients are required to report all changes in income or other circumstances that may affect their eligibility for benefits, including any of the following within 10 days of occurrence:

The date of occurrence is determined as follows:

For changes that are required to be reported, clients may report by telephone, office visit, report form, or other written notice. 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.

Processing Changes - Step-by-Step

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.

arrow 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.

Changes That Must Be Reported: 461-170-0011

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.

461-170-0130

2. Issuing Benefits

QMB-BAS benefits are issued by providing the client with a medical card. Clients that receive SMB and SMF only do not receive a medical card.

Benefits for Clients in an Acute Care Hospital. For an individual already receiving QMB/SMB/SMF when they are admitted to an acute care hospital, benefits can continue as long as they continue to meet program requirements. Remember that after 30 days, individuals are no longer part of their original household group if it contained other individuals (see OAR 461-110-0210(7)).

arrow See MSP B.12 for information on issuing notices.

For more information about issuing benefits, go to Generic Program Elements C.

 

3. Effective Dates

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. This includes when an individual is currently receiving an SMB or SMF and is determined eligible for QMB.

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.

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:

The effective date for starting medical benefits for DW is one of the following, whichever occurs first:

461-180-0090

461-180-0083

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.

461-180-0010

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:

461-180-0120

Redetermination. The effective date for continuing eligibility at the end of the redetermination period is one of the following:

461-180-0100

Closing/Suspending Benefits. The effective date for ending benefits when the only eligible 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 effective date for suspending benefits for a client who receives medical assistance and become incarcerated is the effective date on the decision notice.

461-180-0050

461-180-0050

Denial of Benefits. The effective date for denying benefits is the date the decision was made that the individual is not eligible, including if the ineligibility results from failure to provide information or otherwise cooperate.

461-180-0060

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:

461-180-0130

4. Redetermination

Redetermination is the process used to review eligibility to approve or deny continuing benefits. The redetermination process includes an interview (except for assumed eligible individuals), receipt of any required verification, completion of the Oregon ACCESS tabs and narration for non-converted offices using legacy systems. Normally, individuals must cooperate in the eligibility redetermination or their benefits are closed. However, during the COVID-19 emergency period no adverse actions may be taken, so benefits must remain open at the same or better level until the end of the emergency period.

A signed application is not required during a periodic redetermination or anytime eligibility is redetermined due to reported changes when a signed application (dated 2009 or later for a 539A and 2020 or later for a 7210) is on file.

For all individuals, complete a redetermination at least once every 12 months. Assumed eligibleindividuals are not required to complete an interview at redetermination; however, you must still complete a desk audit every 12 months. Remember to review for other medical programs at redetermination.

Desk audits. Individuals who are not required to interview at redetermination should have an eligibility redetermination at least once a year where the worker reviews for continuing eligibility using available electronic systems such as WQY2, AVS, and The Work number. MSP individuals (unless they are QMB-DW) and OSIPM individuals who are assumed eligible do not have to complete an interview at 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. 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.

Redetermination Process - Non-Converted Offices

Redetermination reports:


SJM4355R-A

SNAP case due for recertification

SJM4300R-A

SNAP eligibility expirations with no recertification

SJM4355R-C

Certification ending SNAP PA

APD-1173

Weekly Medicaid Redetermination - This report lists redeterminations due the previous month, due in the current month, and due in the following month.  This report is updated every Monday.  This is the report eligibility staff should use primarily.

APD-1112

Medicaid Redetermination - This report lists past-due Medicaid redeterminations back to 2012 and is updated the last Monday of each month.  This report should be used primarily by management to track and address overdue redeterminations.

See APD-IM-18-048 for guidance on accessing Medicaid Redetermination Reports through the Office of Business Intelligence (OBI).

SNAP and Medicaid.

For SNAP and APD medical recipients, do not hold up the medical redetermination for the signed application; you may process the medical redetermination after the interview if you do not require verification of any eligibility factors.
All SNAP recipients must complete a new application (539A or 415F) at recertification, regardless of whether or not they are also receiving APD or MAGI Medicaid benefits.

Redetermination forms:

Form # Form name Programs
On OA
Large Print
DHS 210A Notice of Information or Verification Needed All
Y
Y
SDS 446 Benefits Review Application Form Instructions All
N
N
SDS 539A Application for Medicaid, Services and SNAP benefits

Medicaid with SNAP (no application necessary for Medicaid-only)

Y
Y
SDS 539F SNAP Filing Form SNAP (if expired)
Y

Y
LP Spanish

SDS 539H Pending notice All (if necessary)
Y
N
SDS 539R Rights and Responsibilities All
Y
Y
DHS 3400 Resource Guide for Low-Income Families SNAP
Y
Y
LP Spanish
DHS 9001 Client Discrimination Complaint Information All
Y
Y
LP Spanish
APD 9377A Adult Abuse Awareness flyer Medicaid
N
N
EPD
APD 850A Adjusted Income Calculation Sheet EPD
Y
N
APD 850B Employment and Independence Expenses
EPD
Y
N
APD 850C Request for Approved Account EPD
Y
N
APD 850E Notice of Participant Fee EPD
Y
Y

Narrating SSA and other income information obtained electronically through Income and Eligibility and Verification System (IEVS) screens

The Social Security Administration (SSA) has a contract with the Department of Human services called a Computer Matching/Data Exchange Agreement. This agreement allows DHS to populate the BEIN screens, request TPQY updates and produce reports on ViewDirect/Mobius relating to SSA matches. In order to continue these processes, DHS has had to tighten the access to the SSA information or risk losing access entirely. DHS is also able to access other Income Eligibility and Verification System (IEVS) screens with similar compliance requirements.

To ensure that compliance is maintained, it is important to pay attention to narrative entries. Please note that there has been a change to the procedure surrounding narration of IEVS screens (see SS-AR-14-014 for additional information and examples):

Once the information is entered into either FSMIS or CMS (as long as it does not contain a notation that it came from any of the SSA screens), it becomes DHS’s information and can be viewed by those authorized through DHS.

 

461-115-0430


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.

461-180-0085

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