Or. Admin. R. 461-120-0315

Current through Register Vol. 63, No. 9, September 1, 2024

Section 461-120-0315 - Medical Assignment

(1) This rule applies to all applicants for and recipients of medical assistance offered under the state plan.

(2) To the extent that payment for covered expenses has been made under the state medical assistance program for health care items or services furnished to an individual, in any case where a third party has a legal liability to make payments, the state is considered to have acquired the rights of the individual to payment by any other party for those health care items or services. This assignment of rights is automatic in accordance with ORS 659.830 and 743B.470 and does not require the consent of any individual.

(3) When an individual has long-term care insurance, the individual complies with the requirements of this rule by reducing the Department's share of the long-term care (see OAR 461-001-0000) service costs by taking the following actions for the entire period of time that the individual is eligible for Department-covered long-term care services:

(a) For an individual in a nursing facility:

(A) Submitting the necessary paperwork to receive the long-term care insurance payments and designating the long-term care facility as the payee for the long-term care insurance benefits; or

(B) When the insurance company will not pay the long-term care insurance benefits directly to the long-term care facility, submitting the necessary paperwork to receive insurance payments and then promptly turning over the long-term care insurance payments to the long-term care facility upon receipt.

(b) For an individual in community-based care (see OAR 461-001-0000):

(A) Submitting the necessary paperwork to receive the long-term care insurance payments and designating the Department as the payee for the long-term care insurance benefits; or

(B) When the insurance company will not pay the long-term care insurance benefits directly to the Department, submitting the necessary paperwork to receive the insurance payments and then promptly turning over the long-term care insurance payments to the Department upon receipt.

(c) This section of the rule does not supersede section (2) of this rule. The Department may seek payment directly from a long-term care insurer as permitted by ORS 659.830 or 743B.470.

(4) Except as outlined in OAR 461-120-0350, as a condition of eligibility, legally-able individuals must cooperate with the Department to:

(a) Identify any third party liable or potentially liable for medical costs paid by the Department, the Oregon Health Authority, Coordinated Care Organization (CCO), or prepaid managed care health services organization to or on behalf of an individual or any individual applying for or receiving medical assistance under the state plan for whom the individual is legally able;

(b) Provide information about liability or other insurance that may cover or pay for medical costs paid by the Department, the Authority, CCO, or prepaid managed care health services organization to or on behalf of a medical assistance applicant or recipient;

(c) Provide other information as required by the CCO, or prepaid managed care health services organization to assist in pursuing payment from any third party who may be liable for medical costs paid by the Department, the Authority, CCO, or prepaid managed care health services organization to or on behalf of a medical assistance applicant or recipient; and

(d) Comply with the personal injury claim provisions in accordance with OAR 461-195-0303.

(5) The amount the Department may collect in reimbursement is limited to the amount of medical services paid by the Department on behalf of the individual.

(6) The Department establishes an overpayment if it is discovered after-the-fact that during any period of time a long-term care insurance claim is on behalf of the individual and the individual received a long-term care insurance payment that was not turned over to the long-term care facility or Department as required under this rule.

Or. Admin. R. 461-120-0315

AFS 28-1992, f. & cert. ef. 10-1-92; AFS 19-1993, f. & cert. ef. 10-1-93; AFS 2-1994, f. & cert. ef. 2-1-94; AFS 1-2000, f. 1-13-00, cert. ef. 2-1-00; SSP 29-2009(Temp), f. & cert. ef. 10-1-09 thru 3-30-10; SSP 38-2009, f. 12-31-09, cert. ef. 1-1-10; SSP 17-2011, f. & cert. ef. 7-1-11; SSP 9-2012, f. 3-29-12, cert. ef. 4-1-12; SSP 30-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14; ; SSP 38-2013, f. 12-31-13, cert. ef. 1-1-14; SSP 16-2014, f. & cert. ef. 7-1-14; SSP 25-2016(Temp), f. 6-30-16, cert. ef. 7-1-16 thru 12-27-16; SSP 31-2016, f. & cert. ef. 9/1/2016; SSP 23-2017, f. 9-11-17, cert. ef. 10/1/2017; SSP 55-2021, minor correction filed 12/13/2021, effective 12/13/2021

Statutory/Other Authority: ORS 409.050, 411.060, 411.404, 411.706, 413.085, 414.231 & 414.685

Statutes/Other Implemented: ORS 409.010, 411.060, 411.404, 411.706, 414.231, 659.830 & 743B.470