Or. Admin. Code § 410-200-0115

Current through Register Vol. 63, No. 11, November 1, 2024

Section 410-200-0115 - HSD Medical Programs-Effective Dates

(1) This section of the rule identifies the effective date of coverage for new applicants who are approved for HSD Medical Program benefits

(a) For all HSD Medical programs except OHP Bridge - Basic Health Program, the effective date is:

(A) The earliest date of eligibility within the month in which the Date of Request is established; or

(B) If ineligible within the month in which the Date of Request was established, the first day within the following month in which the client is determined to be eligible.

(b) For OHP Bridge - Basic Health Program:

(A) When the determination of eligibility is made on or before the 15th day of a month, the effective date of coverage is on the first day of the month following the month in which the determination was made; or

(B) When the determination of eligibility is made on or after the 16th day of a month, the effective date of coverage is the first day of the month following the next month.

(2) For EXT, the effective date is determined according to OAR 410-200-0440.

(3) The effective date for retroactive medical benefits (OAR 410-200-0130) for MAGI Medicaid/CHIP and BCCTP is the earlier of:

(a) The first day of the earliest of the three (3) months preceding the month in which the Date of Request was established; or

(b) If ineligible pursuant to section (s)(a), the earliest date of eligibility within the three (3) months preceding the month in which the Date of Request was established.

(4) Establishing a renewal date:

(a) For all HSD Medical Programs except EXT (see OAR 410-200-0440), eligibility shall be renewed every twelve (12) months or upon the earliest Continuous Eligibility (CE) period end-date present on the case (see OAR 410-200-0135 Assumed, Continuous, and Protected Eligibility), whichever is later.

(b) For redeterminations that are initiated by a reported change, outside of the established renewal date, the renewal date is not adjusted.

(5) Effective dates of eligibility changes resulting from Reported Changes (also see Changes That Must Be Reported OAR 410-200-0235):

(a) When the beneficiary reports a change in circumstances, eligibility shall be redetermined for all EDG members;

(b) When a reported change results in a reduction or loss of eligibility, the effective date for the change is:

(A) If the determination is made on or before the 15th of the month, the first of the next month; or

(B) If the determination is made on or after the 16th of the month, the first of the month following the next month.

(c) For reported changes which result in a determination of ongoing eligibility for an HSD Medical Program at the same benefit level, the effective date of the change is the 1st of the month following the date of processing.

(d) For beneficiaries who report a pregnancy, the effective date of the pregnancy-related HSD Medical Program benefit is the earlier of:

(A) The first of the month in which the pregnancy is reported; or

(B) The date that a prenatal service related to the pregnancy was received.

(e) For beneficiaries of CWM-level benefits who report a change that results in eligibility for Plus level benefits, the effective date of the Plus-level benefit is the first of the month which it's reported.

(6) Suspending or Closing Medical Benefits:

(a) The effective date for closing HSD Medical Program benefits is the earliest of:

(A) The date of a beneficiary's death;

(B) The last day of the month in which the beneficiary becomes ineligible and a timely continuing benefit decision notice is sent;

(C) The day prior to the start date for Office of Child Welfare Programs or OSIPM for beneficiaries transitioning from an HSD Medical Program;

(D) The date the program ends; or

(E) The last day of the month in which a timely continuing benefit decision notice is sent if ongoing eligibility cannot be determined because the beneficiary does not provide required information by the deadline provided.

(b) Except for benefits obtained via Hospital Presumptive Eligibility (see OAR 410-200-0105) or a presumptive eligibility period for BCCTP (see OAR 410-200-0400), prior to closing medical benefits, the Agency shall:

(A) Determine eligibility for all other HSD Medical Programs; or

(B) Refer the beneficiary to the Department, if applicable, and confirm that the Department has made an eligibility decision.

(c) For beneficiaries of HSD Medical Program benefits who become incarcerated (OAR 410-200-0140), the effective date of suspension is the day following the date on which the individual became incarcerated.

(7) Denial of Benefits. The effective date for denying HSD Medical Program benefits is the earlier of the following:

(a) The date the decision is made that the applicant is not eligible and notice is sent; or

(b) The end of the application processing time frame, unless the time period has been extended to allow the applicant more time to provide required verification.

Or. Admin. Code § 410-200-0115

DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1/30/2015; DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16; DMAP 24-2016, f. & cert. ef. 6/2/2016; DMAP 23-2020, amend filed 05/07/2020, effective 5/8/2020; DMAP 33-2020, temporary amend filed 06/29/2020, effective 7/6/2020 through 1/1/2021; DMAP 67-2020, amend filed 12/22/2020, effective 1/1/2021; DMAP 31-2022, minor correction filed 02/16/2022, effective 2/16/2022; DMAP 94-2024, amend filed 05/29/2024, effective 6/1/2024

Statutory/Other Authority: ORS, 411.402, 411.404, 413.042 & 414.534

Statutes/Other Implemented: ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.447, 414.534, 414.536 & 414.706