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Oregon Bulletin

September 1, 2013

Department of Human Services, Self-Sufficiency Programs, Chapter 461

Rule Caption: Changing OARs affecting public assistance, medical assistance, or Supplemental Nutrition Assistance Program clients

Adm. Order No.: SSP 18-2013(Temp)

Filed with Sec. of State: 7-31-2013

Certified to be Effective: 8-1-13 thru 12-28-13

Notice Publication Date:

Rules Amended: 461-155-0575

Rules Suspended: 461-155-0575(T)

Subject: OAR 461-155-0575 about in-home supplementation in the Oregon Supplemental Income Program Medical (OSIPM) which was amended by temporary rule on July 1, 2013 is being further amended to reduce the monthly payment from $30 to $15 effective September 1, 2013.

Rules Coordinator: Annette Tesch—(503) 945-6067

461-155-0575

Special Need; In-home Supplement; OSIPM

In the OSIPM program:

(1) The Department may provide a monthly supplementary payment for a client who meets the requirements of all of the following subsections:

(a) The client must receive SSI as his or her only source of income.

(b) The client must receive home and community-based care (see OAR 461-001-0030) in-home services or State Plan Personal Care Services authorized under chapter 411, division 034 of Oregon Administrative Rules.

(2) An eligible client (under section (1) of this rule) receives a $30 monthly payment through August 31, 2013. Effective September 1, 2013 the monthly payment will be $15. The payment is considered reimbursement for uncovered assistance needs.

Stat. Auth.: ORS 411.060, 411.070, 411.404 & 411.706

Stats. Implemented: ORS 411.060, 411.070, 411.083, 411.404, 411.704 & 411.706

Hist.: SSP 11-2011(Temp), f. 3-31-11, cert. ef. 4-1-11 thru 9-28-11; SSP 17-2011, f. & cert. ef. 7-1-11; SSP 21-2011(Temp), f. & cert. ef. 7-15-11 thru 1-11-12; SSP 31-2011(Temp), f. & cert. ef. 12-1-11 thru 1-11-12; Administrative correction, 2-6-12; SSP 33-2012(Temp), f. 10-31-12, cert. ef. 11-1-12 thru 4-30-13; SSP 8-2013, f. & cert. ef. 4-1-13; SSP 17-2013(Temp), f. & cert. ef. 7-1-13 thru 12-28-13; SSP 18-2013(Temp), f. 7-31-13, cert. ef. 8-1-13 thru 12-28-13


Rule Caption: Changing OARs affecting public assistance, medical assistance, or Supplemental Nutrition Assistance Program clients

Adm. Order No.: SSP 19-2013(Temp)

Filed with Sec. of State: 7-31-2013

Certified to be Effective: 8-1-13 thru 1-28-14

Notice Publication Date:

Rules Amended: 461-115-0050, 461-135-1102, 461-150-0055, 461-150-0060, 461-180-0010, 461-180-0090

Subject: OAR 461-115-0050 about when an application must be filed, OAR 461-135-1102 about effective dates for the OHP-OPU program, OAR 461-150-0055 about eligibility and budgeting for HKC and OHP, OAR 461-180-0010 about effective dates for adding a new person to an open case, and OAR 461-180-0090 about effective dates for initial month of medical benefits are being amended to allow usage of only the initial budget month and the month following the initial budget month in determining eligibility for Substitute and Adoptive Care (for children in behavioral and rehabilitation services and psychiatric residential treatment), Medical Assistance Assumed, Medical Assistance to Families, Oregon Health Plan (including CAWEM related to OHP-OPU), and Healthy KidsConnect medical programs. These amendments also allow, if determined eligible, starting medical benefits no later than the last day of the month following the month of application without requiring a new application (instead of 45 days from the date of request). OAR 461-115-0050 is also being amended to remove the specific situation where a new application is not required for children under age 19 with a date of request from July 1, 2009 through December 31, 2009 who were denied for medical other than failure to complete the application requirements when the Department chooses to redetermine the child’s eligibility for rules in effect October 1, 2009 and January 1, 2010 because this situation is no longer applicable.

   OAR 461-150-0060 about prospective budgeting and eligibility is being amended to clarify that actual income is used when there is a new or terminated source of income in the initial month of eligibility for the Temporary Assistance for Needy Families (TANF) and Refugee programs.

Rules Coordinator: Annette Tesch—(503) 945-6067

461-115-0050

When an Application Must Be Filed

(1) A client must file an application, or may amend a completed application, as a prerequisite to receiving benefits as follows:

(a) A client may apply for the TA-DVS program as provided in OAR 461-135-1220.

(b) In all programs except the TA-DVS program:

(A) Except as provided otherwise in this rule, a client wishing to apply for program benefits must submit a complete application on a form approved by the Department.

(B) An application is complete if all of the following requirements are met:

(i) All information necessary to determine the individual’s eligibility and benefit amount is provided on the application for each individual in the filing group.

(ii) The applicant, even if homeless, provides a mailing address.

(iii) The application is signed. An individual required but unable to sign the application may sign with a mark, witnessed by another individual.

(iv) The application is received by the Department, except an electronic application (see OAR 461-001-0000) meets the requirements of this paragraph only when submitted to and received by the Department with an electronic signature.

(2) A new application is not required in the following situations:

(a) In the SNAP program, when a single application can be used both to determine a client is ineligible in the month of application and to determine the client is eligible the next month. This can be done when:

(A) Anticipated changes make the filing group (see OAR 461-110-0370) eligible the second month; or

(B) The filing group provides verification between 30 and 60 days following the filing date (see OAR 461-115-0040), under OAR 461-180-0080.

(b) In all programs except the HKC, MAA, MAF, OHP, SAC, and SNAP programs, when a single application can be used both to determine a client is ineligible on the date of request (see OAR 461-115-0030) and to determine the client is eligible when anticipated changes make the filing group eligible within 45 days from the date of request.

(c) In the HKC, MAA, MAF, OHP, and SAC programs, when a single application can be used both to determine a client is ineligible in the month of application and to determine the applicant is eligible the following month.

(d) When the case is closed and reopened during the same calendar month.

(e) When benefits were suspended for one month because of the level of income, and the case is reopened the month following the month of suspension.

(f) When reinstating medical benefits for a pregnant woman covered by OAR 461-135-0950, notwithstanding subsection (g) of this section.

(g) In the BCCM, CEC, CEM, EXT, GAM, MAA, MAF, OHP, OSIPM, QMB, and SAC programs, when a client’s medical benefits are suspended because the client lives in a public institution (see OAR 461-135-0950), if the inmate is released within 12 months of admission and the inmate provides notification to the Department within 10 days of the release.

(3) When a client establishes a new date of request (see OAR 461-115-0030) prior to the end of the month following the month of case closure, unless the Department determines a new application is required, a new application is not required in the following situations:

(a) In the OSIPM program, when the client’s case closed due to failure to make a liability payment required under OAR 461-160-0610.

(b) In the OSIPM-EPD program, when the client’s case closed due to failure to make a participant fee payment required under OAR 461-160-0800.

(4) A new application is required to add a newborn child to a benefit group (see OAR 461-110-0750) according to the following requirements:

(a) For the REF and TANF programs:

(A) A new application is not required if the child is listed on the application as “unborn” and there is sufficient information about the child to establish its eligibility.

(B) A new application is required if the child is not included on the application as “unborn.”

(b) In the CEC, CEM, EXT, HKC, MAA, MAF, OHP, and REFM programs, no additional application is required to add a newborn to a benefit group receiving benefits from one of the listed programs if eligibility can be determined without submission of a new application.

(c) In the CEC, CEM, EXT, GAM, HKC, MAA, MAF, OHP, OSIPM, QMB, REFM, and SAC programs, no additional application is required to add an assumed eligible newborn to a benefit group currently receiving Department medical program benefits.

(d) In the ERDC and SNAP programs, an application is not required to add the child to the benefit group.

(e) In all programs other than CEC, CEM, ERDC, EXT, GAM, HKC, MAA, MAF, OHP, QMB, REF, REFM, SAC, SNAP, and TANF, an application is required.

(5) A new application is required to add an individual, other than a newborn child, to a benefit group according to the following requirements:

(a) In the ERDC and SNAP programs, a new application is not required.

(b) In the EXT, HKC, MAA, MAF, OHP, REF, REFM, SAC, and TANF programs, an individual may be added by amending a current application if the information is sufficient to determine eligibility; otherwise a new application is required.

(c) In all programs other than the ERDC, EXT, HKC, MAA, MAF, OHP, REF, REFM, SAC, SNAP, and TANF programs, a new application is required.

(6) A client whose TANF grant is closing may request ERDC orally or in writing.

(7) Except for an applicant for the SNAP program, a client may change between programs administered by the Department using the current application if the following conditions are met:

(a) The client makes an oral or written request for the change.

(b) The Department has sufficient evidence to determine eligibility and benefit level for the new program without a new application.

(c) The program change can be effected while the client is eligible for the first program.

(8) In the CEC, CEM, EXT, HKC, MAA, MAF, OHP, OSIP, OSIPM, and QMB programs, a new application is not required to redetermine eligibility if the following conditions are met:

(a) The client currently is receiving benefits from one of these programs; and

(b) The Department has sufficient evidence to redetermine eligibility for the same program or determine eligibility for the new program without a new application or by amending the current application.

Stat. Auth: ORS 409.050, 411.060, 411.070, 411.404, 411.704, 411.706, 411.816, 412.049, 414.025, 414.231, 414.826, 414.839

Stats. Implemented: ORS 409.050, 411.060, 411.070, 411.117, 411.404, 411.704, 411.706, 411.816, 412.049, 414.025, 414.231, 414.826, 414.839

Hist.: AFS 80-1989, f. 12-21-89, cert. ef. 2-1-90; AFS 12-1990, f. 3-30-90, cert. ef. 4-1-90; AFS 23-1990, f. 9-28-90, cert. ef. 10-1-90; AFS 30-1990, f. 12-31-90, cert. ef. 1-1-91; AFS 3-1991(Temp), f. & cert. ef. 1-17-91; AFS 13-1991, f. & cert. ef. 7-1-91; AFS 2-1992, f. 1-30-92, cert. ef. 2-1-92; AFS 20-1992, f. 7-31-92, cert. ef. 8-1-92; AFS 12-1993, f. & cert. ef. 7-1-93; AFS 2-1994, f. & cert. ef. 2-1-94; AFS 10-1995, f. 3-30-95, cert. ef. 4-1-95; AFS 27-1996, f. 6-27-1996, cert. ef. 7-1-96; AFS 36-1996, f. 10-31-96, cert. ef. 11-1-96; AFS 9-1997, f. & cert. ef. 7-1-97; AFS 13-1997, f. 8-28-97, cert. ef. 9-1-97; AFS 4-1998, f. 2-25-98, cert. ef. 3-1-98; AFS 5-1998(Temp), f. & cert. ef. 3-11-98 thru 5-31-98; AFS 8-1998, f. 4-28-98, cert. ef. 5-1-98; AFS 17-1998, f. & cert. ef. 10-1-98; AFS 2-1999, f. 3-26-99, cert. ef. 4-1-99; AFS 1-2000, f. 1-13-00, cert. ef. 2-1-00; AFS 25-2000, f. 9-29-00, cert. ef. 10-1-00; AFS 19-2001, f. 8-31-01, cert. ef. 9-1-01; AFS 21-2001(Temp), f. & cert. ef. 10-1-01 thru 12-31-01; AFS 22-2001, f. & cert. ef. 10-1-01; AFS 27-2001, f. 12-21-01, cert. ef. 1-1-02; SSP 22-2004, f. & cert. ef. 10-1-04; SSP 4-2005, f. & cert. ef. 4-1-05; SSP 15-2006, f. 12-29-06, cert. ef. 1-1-07; SSP 7-2007, f. 6-29-07, cert. ef. 7-1-07; SSP 10-2007, f. & cert. ef. 10-1-07; SSP 2-2008(Temp), f. & cert. ef. 1-28-08 thru 6-30-08; SSP 17-2008, f. & cert. ef. 7-1-08; SSP 26-2008, f. 12-31-08, cert. ef. 1-1-09; SSP 13-2009, f. & cert. ef. 7-1-09; SSP 17-2009(Temp), f. 7-29-09, cert. ef. 8-1-09 thru 1-28-10; SSP 22-2009(Temp), f. & cert. ef. 8-28-09 thru 1-28-10; SSP 38-2009, f. 12-31-09, cert. ef. 1-1-10; SSP 39-2009(Temp), f. 12-31-09, cert. ef. 1-1-10 thru 6-30-10; SSP 18-2010, f. & cert. ef. 7-1-10; SSP 26-2011(Temp), f. 9-30-11, cert. ef. 10-1-11 thru 3-29-12; SSP 35-2011, f. 12-27-11, cert. ef. 1-1-12; SSP 19-2013(Temp), f. 7-31-13, cert. ef. 8-1-13 thru 1-28-14

461-135-1102

OHP-OPU; Effective Dates for the Program

(1) Effective July 1, 2004, the OHP-OPU program is closed to new applicants other than an OHP Reservation List Applicant permitted under OAR 461-135-1125. Except as provided in sections (2) to (3) of this rule, a new applicant is an individual with a date of request (see OAR 461-115-0030) after June 30, 2004. A new applicant cannot be found eligible for the OHP-OPU program.

(2) An individual is not a new applicant if the Department determines that the individual is continuously eligible for medical assistance as follows:

(a) The individual is eligible for and receiving benefits under the OHP-OPU program on June 30, 2004, or after that date pursuant to subsections (b) to (e) of this section, and the Department determines that the individual continues after that date to meet the eligibility requirements for the OHP-OPU program.

(b) The individual is eligible for and receiving benefits under the CAWEM program on June 30, 2004, and is eligible for the CAWEM program based on the OHP-OPU program, and the Department determines that the individual continues to meet the eligibility requirements for the OHP-OPU program except for citizenship or alien status requirements.

(c) The eligibility of the individual ends under the BCCM, CEC, CEM, EXT, GAM, HKC, MAA, MAF, OHP-CHP, OHP-OPC, OHP-OPP, OSIPM, REFM, or SAC program, or the related CAWEM program; or because the individual has left the custody of the Oregon Youth Authority (OYA); and at that time the Department determines that the individual meets the eligibility requirements for the OHP-OPU program.

(d) The individual is a child in the custody of the Department whose eligibility for Medicaid ends because of the child’s age and at that time the Department determines that the individual meets the eligibility requirements for the OHP-OPU program.

(e) The Department determines that the individual was continuously eligible for the OHP-OPU program on or after June 30, 2004 under subsections (a) to (d) of this section.

(3) An individual who is not continuously eligible under section (2) of this rule is not a new applicant if the individual:

(a) Has eligibility end under the BCCM, CEC, CEM, EXT, GAM, HKC, MAA, MAF, OHP-CHP, OHP-OPP, OHP-OPU, OSIPM, REFM, or SAC program, or the related CAWEM program; because the individual has left the custody of the OYA; or is a child in the custody of the Department whose eligibility for Medicaid ends due to the child’s age;

(b) Established a date of request prior to the eligibility ending date in subsection (a) of this section; and

(c) Meets the eligibility requirements for the OHP-OPU program or the related CAWEM program within either the month of the date of request or, if ineligible in the month of the date of request, the following month.

(4) An individual who is not continuously eligible under section (2) of this rule is not a new applicant if the individual is a Family Health Insurance Assistance Program (FHIAP) recipient who:

(a) Is notified by FHIAP that the recipient’s subsidy will end on or after November 30, 2012 due to budget shortfalls;

(b) Is determined by FHIAP to be eligible for OHP-OPU; and

(c) Indicates to FHIAP that the recipient agrees to move to OHP-OPU.

(5) Except as provided in section (2) of this rule, an individual who loses eligibility for a medical assistance program and applies or reapplies for medical assistance is treated as a new applicant for purposes of the OHP-OPU program.

(6) The Department intends that effective July 1, 2004, all other rules related to application, certification, recertification, or eligibility for the OHP-OPU program be applied and construed to achieve the purpose of this rule and that in the event of any ambiguity this rule controls.

Stat. Auth.: ORS 409.050, 411.060, 411.070, 411.404, 414.712 & 414.826

Stats. Implemented: ORS 409.010, 411.060, 411.070, 411.404, 414.712, 414.826, 414.831, 414.839, 420.014 & 420.054

Hist.: SSP 17-2004, f. & cert. ef. 7-1-04; SSP 4-2005, f. & cert. ef. 4-1-05; SSP 2-2008(Temp), f. & cert. ef. 1-28-08 thru 6-30-08; SSP 13-2008(Temp), f. 5-30-08, cert. ef. 6-1-08 thru 6-30-08; SSP 17-2008, f. & cert. ef. 7-1-08; SSP 26-2008, f. 12-31-08, cert. ef. 1-1-09; SSP 10-2010(Temp), f. & cert. ef. 4-21-10 thru 10-18-10; SSP 32-2010, f. & cert. ef. 10-1-10; SSP 35-2012(Temp), f. 11-30-12, cert. ef. 12-1-12 thru 5-30-13; SSP 8-2013, f. & cert. ef. 4-1-13; SSP 19-2013(Temp), f. 7-31-13, cert. ef. 8-1-13 thru 1-28-14

461-150-0055

Eligibility and Budgeting; HKC, OHP

In the HKC and OHP programs:

(1) The budget month (see OAR 461-001-0000) is:

(a) For a new applicant, the month of application.

(b) For a client reapplying at the end of an OHP certification period (see OAR 461-001-0000), no longer eligible for his or her current OHP program, or moving from the BCCM, EXT, GAM, MAA, MAF, OSIPM, REFM, or SAC programs to the OHP program: the last month of the current eligibility (see OAR 461-001-0000) period.

(c) For a client reapplying at the end of an HKC certification period, the tenth month of the HKC certification period.

(d) When the Department initiates a redetermination of eligibility:

(A) The last month of the current OHP program eligibility period if the Department initiates the redetermination by sending a DHS 945 form.

(B) For OHP program cases not covered by paragraph (A) of this subsection, the month the Department initiates a date of request (see OAR 461-115-0030).

(e) For an individual joining a filing group (see OAR 461-110-0400), the month in which the individual requests medical benefits.

(f) For a late reapplication, the month the Department receives the new application.

(g) For a new applicant or current recipient who is not eligible using the budget month described in subsections (1)(a) to (1)(d) of this rule, the month following the initial budget month.

(2) Countable (see OAR 461-001-0000) income is determined as follows:

(a) Income is considered available during a month under OAR 461 140 0040.

(b) Income is not annualized, converted, or prorated.

(c) For a self-employed client, countable self-employment income is determined under OAR 461-145-0920 and 461-145-0930.

(3) Except as provided in section (5) of this rule, the Department calculates the countable income of the financial group (see OAR 461-110-0530) by adding together the income the financial group has already received in the budget month and the income that reasonably may be expected to be received in the budget month.

(4) A change in income or resources during a certification period (see OAR 461-001-0000) does not affect the eligibility of the benefit group (see OAR 461-110-0750) for that certification period.

(5) In the HKC, OHP-CHP, and OHP-OPC programs, when the Department uses a finding made during an ELE determination and the child meets all other HKC, OHP-CHP, or OHP-OPC program nonfinancial eligibility requirements, the standard for the number of eligibility group members determined by the ELA is used to determine eligibility regardless of the need group (see OAR 461-110-0630) size. The countable income of the financial group is the same as the income amount determined by the ELA.

(a) A child is deemed eligible for the HKC, OHP-CHP, or OHP-OPC program as follows:

(A) If the income of the need group is below 163 percent of the federal poverty level (FPL) as listed in OAR 461-155-0180, the Department deems the child eligible for OHP-OPC.

(B) If the income of the need group is at or above 163 percent of the FPL but under 201 percent of the FPL, the Department deems the child eligible for OHP-CHP.

(C) If the income of the need group is at or above 201 percent of the FPL, the Department deems the child eligible for HKC.

(b) If the income of the need group is above 301 percent of the FPL, the Department determines eligibility using the standard medical assistance eligibility determination processes.

Stat. Auth.: ORS 409.050, 411.060, 411.070, 411.404, 414.231

Stats. Implemented: ORS 409.010, 411.060, 411.070, 411.404, 414.231

Hist.: AFS 2-1994, f. & cert. ef. 2-1-94; AFS 22-1995, f. 9-20-95, cert. ef. 10-1-95; AFS 10-1998, f. 6-29-98, cert. ef. 7-1-98; AFS 24-1998(Temp), f. 11-30-98, cert. ef. 12-1-98 thru 3-31-99; AFS 2-1999, f. 3-26-99, cert. ef. 4-1-99; AFS 3-2000, f. 1-31-00, cert. ef. 2-1-00; AFS 3-2000, f. 1-31-00, cert. ef. 2-1-00; SSP 1-2003, f. 1-31-03, cert. ef. 2-1-03; SSP 4-2005, f. & cert. ef. 4-1-05; SSP 7-2005, f. & cert. ef. 7-1-05; SSP 6-2006, f. 3-31-06, cert. ef. 4-1-06; SSP 15-2006, f. 12-29-06, cert. ef. 1-1-07; SSP 13-2009, f. & cert. ef. 7-1-09; 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 25-2010(Temp), f. & cert. ef. 8-16-10 thru 2-12-11; SSP 38-2010(Temp), f. & cert. ef. 11-1-10 thru 2-12-11; SSP 41-2010, f. 12-30-10, cert. ef. 1-1-11; SSP 43-2010(Temp), f. 12-30-10, cert. ef. 1-1-11 thru 4-30-11; SSP 5-2011(Temp), f. & cert. ef. 2-4-11 thru 4-30-11; SSP 10-2011, f. 3-31-11, cert. ef. 4-1-11; SSP 19-2013(Temp), f. 7-31-13, cert. ef. 8-1-13 thru 1-28-14

461-150-0060

Prospective or Retrospective Eligibility and Budgeting; ERDC, MAA, MAF, REF, REFM, SNAP, TANF

In the ERDC, MAA, MAF, REF, REFM, SNAP, and TANF programs, the Department determines how and when to use prospective or retrospective eligibility (see OAR 461-001-0000) and budgeting (see OAR 461-001-0000) as follows:

(1) For the initial month (see OAR 461-001-0000):

(a) In the ERDC program, income is budgeted so the anticipated amount is the same for each month, including the initial month.

(b) For an MAA and MAF case, or a SNAP case in CRS, the Department uses actual income (see subsection (h) of this section) in the initial month.

(c) For a SNAP program case in SRS, actual income is used in the initial month if that income is not reflective of ongoing monthly income due to a new or terminated source or a significant change in ongoing income. All other income is processed under section (3) of this rule.

(d) In the REF and TANF programs, ongoing income, processed under section (2) of this rule, is used in the initial month, except when the source of income is a new or terminated source. When there is a new or terminated source of income, actual income is used in the initial month.

(e) In the REFM program:

(A) When a client has moved to Oregon from the client’s original resettlement state, see OAR 461-135-0010.

(B) For a client not assumed eligible under paragraph (A) of this subsection and OAR 461-135-0010, the Department uses only the initial month for eligibility and budgeting.

(f) The Department uses prospective eligibility and budgeting under OAR 461-150-0020 for cases not covered under subsections (a) to (e) of this section, including for a client who leaves a filing group because of domestic violence (see OAR 461-001-0000) and enters a domestic violence shelter (see OAR 461-001-0000) or safe home (see OAR 461-001-0000).

(g) No supplement is issued based on incorrectly anticipated information.

(h) “Actual income” is the income already received in the initial month plus all the income that reasonably may be expected to be received within the initial month.

(2) Income is budgeted so that the anticipated amount is the same for each month. The type of income is determined and calculated as follows:

(a) Income that must be annualized is calculated under OAR 461-150-0090 to arrive at a monthly figure.

(b) Educational income (see OAR 461-145-0150) is assigned to the months it is intended to cover, regardless of when it is received. The income is prorated over these months.

(c) Ongoing stable income (see OAR 461-001-0000) is anticipated under OAR 461-150-0070.

(d) Ongoing variable income (see OAR 461-001-0000) is anticipated under OAR 461-150-0080.

(e) Periodic income (see OAR 461-001-0000) is anticipated under OAR 461-140-0100 and 461-140-0110.

(f) Lump-sum income (see OAR 461-001-0000) is anticipated under OAR 461-140-0100, 461-140-0200, and 461-140-0123.

(g) In the ERDC program, for temporary income and other situations when the child care need will last two consecutive months or less, the income is anticipated to be received in the months of child care need and calculated under OAR 461-150-0080.

(3) For an ongoing month (see OAR 461-001-0000):

(a) For a benefit group (see OAR 461-110-0750), the Department uses prospective eligibility and budgeting. The type of income is determined and calculated under section (2) of this rule.

(b) If the budgeting method changes from prospective to retrospective, the Department treats income from a terminated source that was counted prospectively as follows:

(A) If the actual amount received was less than or equal to the anticipated amount, the income is excluded.

(B) If the actual amount received was greater than the anticipated amount, the Department counts the difference between actual and anticipated amounts.

(4) When an individual is added to an ongoing filing and benefit group, prospective budgeting is used to determine eligibility.

(5) In the ERDC and SNAP programs, income reported on the Interim Change Report form under OAR 461-170-0011 and 461-170-0102 is used to determine eligibility and benefit level. Income for the fifth month of the SNAP program certification period (see OAR 461-001-0000) is used to determine the income for the seventh and following months in the certification period if the client anticipates it will remain the same throughout the period. If the client anticipates the income will change, the client and the Department jointly estimate the income for the remaining months of the certification period. For a client who had self-employment income annualized, no change is made unless there is a substantial change in the revenue of the business.

Stat. Auth.: ORS 411.060, 411.070, 411.404, 411.816 & 412.049

Stats. Implemented: ORS 411.060, 411.070, 411.404, 411.816 & 412.049

Hist.: AFS 80-1989, f. 12-21-89, cert. ef. 2-1-90; AFS 20-1990, f. 8-17-90, cert. ef. 9-1-90; AFS 30-1990, f. 12-31-90, cert. ef. 1-1-91; AFS 19-1993, f. & cert. ef. 10-1-93; AFS 6-1994, f. & cert. ef. 4-1-94; AFS 13-1994, f. & cert. ef. 7-1-94; AFS 10-1995, f. 3-30-95, cert. ef. 4-1-95; AFS 3-1997, f. 3-31-97, cert. ef. 4-1-97; AFS 9-1997, f. & cert. ef. 7-1-97; AFS 3-2000, f. 1-31-00, cert. ef. 2-1-00; AFS 6-2001, f. 3-30-01, cert. ef. 4-1-01; SSP 10-2007, f. & cert. ef. 10-1-07; SSP 13-2009, f. & cert. ef. 7-1-09; SSP 5-2010, f. & cert. ef. 4-1-10; SSP 13-2013, f. & cert. ef. 7-1-13; SSP 19-2013(Temp), f. 7-31-13, cert. ef. 8-1-13 thru 1-28-14

461-180-0010

Effective Dates; Adding a New Person to an Open Case

(1) In the following programs, the effective date for adding an individual (other than an assumed eligible newborn) to the benefit group (see OAR 461-110-0750) is one of the following:

(a) In the GAM, OSIPM, and REFM programs, it is whichever occurs first:

(A) The date the client requests benefits, if the client was eligible as of that date.

(B) The date all eligibility requirements are met.

(b) In the MAA, MAF, OHP, and SAC programs, it is whichever occurs first:

(A) The date the client requests benefits, if the client was eligible as of that date.

(B) The first day following the date of request (see OAR 461-115-0030) that all eligibility requirements are met within the month of the date of request or the following month.

(c) In the HKC program, it is the date a child (see OAR 461-001-0000) is determined eligible for a referral to the HKC program. The Office of Private Health Partnerships (OPHP) determines the effective date for enrolling an eligible child in one of the HKC program categories of coverage.

(d) In the SNAP program:

(A) If adding the individual increases benefits, it is the first of the month after the filing group (see OAR 461-110-0370) reports the person has joined the household group (see OAR 461-110-0210). If verification is requested, the effective date for the change is:

(i) The first of the month following the date the change was reported if verification is received by the Department no later than the due date for the verification.

(ii) The first of the month following the date the verification is received by the Department, if received after the verification due date.

(B) If adding the individual reduces benefits, it is the first of the month following the month in which the notice period ends (see OAR 461-175-0050).

(e) In the GA, OSIP, REF, SFPSS, and TANF programs, it is the date on which all eligibility requirements are met and verified. If benefits have been issued for the month and adding the new person would reduce benefits, the person is added the first of the month following the month in which the notice period ends (see OAR 461-175-0050).

(f) In the QMB-BAS and QMB-DW programs, it is the first of the month after the new individual has been determined to meet all QMB eligibility criteria and the Department receives the required verification.

(g) In the QMB-SMB program, it is the first of the month in which the new individual has been determined to meet all QMB-SMB eligibility criteria and the Department receives the required verification.

(h) In the SFPSS and TANF programs, for adding a child to be covered by a provider-direct child care payment, it is the first of the month in which the child is added to the benefit group.

(2) In the following programs, the effective date for adding an assumed eligible newborn to the benefit group is one of the following:

(a) In the EXT, GAM, MAA, MAF, OHP, OSIPM, REFM, and SAC programs, it is the date of birth if all the following paragraphs are true. If any of the following paragraphs is not true, the newborn is added to the benefit group in accordance with section (1) of this rule.

(A) A request for benefits is made within one year of the birth. For purposes of this paragraph, a telephone call from the attending physician, another licensed practitioner, a hospital, or the family is considered a request for benefits.

(B) The newborn has continuously lived with the mother since the date of birth.

(C) The mother was receiving EXT, GAM, MAA, MAF, OHP, OSIPM, or SAC on the date of birth, even if she is not currently eligible for benefits.

(b) In the SFPSS and TANF programs, it is:

(A) The date of birth, if all eligibility requirements are met and verified within 45 days after the birth; or

(B) The date all eligibility factors are met and verified, if the verification is completed more than 45 days after the date of birth.

(3) In the ERDC program, the effective date for adding an individual to the need group (see OAR 461-110-0630) or benefit group is as follows:

(a) If adding the individual to the need group will decrease the copay, the effective date is the first of the month after the client reports the person has joined the household.

(b) If adding the individual to the need group increases the copay’s for instance, because the individual receives income the effective date is the first of the month following the end of the decision notice period (see OAR 461-175-0050).

(c) The effective date for adding a child to the benefit group’s that is, covering the cost of the child’s care’sis the earliest of the following:

(A) For newborns, the date of birth, if all eligibility requirements are met and verified within 45 days after the birth.

(B) For all other children, the first of the month in which the change is reported, if all eligibility requirements are met and verified within 45 days.

(C) For newborns and other children, if eligibility cannot be verified within 45 days, the effective date is the first of the month in which all eligibility factors are met and verified.

Stat. Auth.: ORS 411.060, 411.070, 411.816, 414.042, 412.049, 2007 OL. 861

Stats. Implemented: ORS 411.060, 411.070, 411.816, 414.042, 412.049, 2007 OL. 861

Hist.: AFS 80-1989, f. 12-21-89, cert. ef. 2-1-90; AFS 20-1990, f. 8-17-90, cert. ef. 9-1-90; AFS 23-1990, f. 9-28-90, cert. ef. 10-1-90; AFS 13-1991, f. & cert. ef. 7-1-91; AFS 2-1992, f. 1-30-92, cert. ef. 2-1-92; AFS 8-1992, f. & cert. ef. 4-1-92; AFS 20-1992, f. 7-31-92, cert. ef. 8-1-92; AFS 12-1993, f. & cert. ef. 7-1-93; AFS 2-1994, f. & cert. ef. 2-1-94; AFS 22-1995, f. 9-20-95, cert. ef. 10-1-95; AFS 36-1996, f. 10-31-96, cert. ef. 11-1-96; AFS 19-1997, f. & cert. ef. 10-1-97; SSP 7-2003, f. & cert. ef. 4-1-03; SSP 17-2004, f. & cert. ef. 7-1-04; SSP 4-2007, f. 3-30-07, cert. ef. 4-1-07; SSP 11-2007(Temp), f. & cert. ef. 10-1-07 thru 3-29-08; SSP 5-2008, f. 2-29-08, cert. ef. 3-1-08; SSP 19-2013(Temp), f. 7-31-13, cert. ef. 8-1-13 thru 1-28-14

461-180-0090

Effective Dates; Initial Month Medical Benefits

The effective date for starting medical benefits for an eligible client is as follows:

(1) In the CEC and CEM programs, it is the first of the month following the month that eligibility for Child Welfare medical, EXT, MAA, MAF, OHP, OHP-CHP, OSIPM, or SAC program benefits ends.

(2) In the EXT program, it is the first of the month following the month that MAA or MAF program eligibility ends.

(3) In the GAM, OSIPM, QMB-DW, and REFM programs:

(a) Except as provided for in subsections (b) and (c) of this section:

(A) If the client meets all eligibility requirements on the date of request (see OAR 461-115-0030), it is the date of request. An OSIPM program client who is assumed eligible under OAR 461-135-0010(7) meets “all eligibility requirements” for the purposes of this section as follows:

(i) Effective the first day of the month of the initial SSI payment if the client is age 21 or older.

(ii) Effective the first day of the month prior to the month of the initial SSI payment if the client is under the age of 21.

(B) If the client does not meet all eligibility requirements on the date of request, it is the first day following the date of request that all eligibility requirements are met.

(b) If the client does not complete the application within the time period described in OAR 461-115-0190 (including the authorized extension), the determination of an effective date requires a new date of request.

(c) Except for OSIPM long-term care services eligibility, if an HKC program client meets all eligibility requirements for the OSIPM program, it is the first of the month following the month in which the Department makes the eligibility determination.

(4) In the MAA, MAF, OHP, and SAC programs:

(a) Except as provided otherwise in subsections (b) and (c) of this section:

(A) If the client meets all eligibility requirements on the date of request, it is the date of request.

(B) If the client does not meet all eligibility requirements on the date of request, it is the first day following the date of request that all eligibility requirements are met within the month of the date of request or the following month.

(b) If the client does not complete the application within the time period described in OAR 461-115-0190 (including the authorized extension), the determination of an effective date requires a new date of request.

(c) If an HKC program client meets all eligibility requirements for the MAA, MAF, OHP, or SAC program, it is the first of the month following the month in which the Department makes the eligibility determination.

(5) In the HKC program, the Office of Private Health Partnerships (OPHP) determines the effective date for enrolling an eligible child in one of the HKC program categories of coverage.

(6) In the QMB-BAS program, it is the first of the month after the benefit group (see OAR 461-110-0750) has been determined to meet all QMB-BAS program eligibility criteria and the Department receives the required verification.

(7) In the QMB-SMB and QMB-SMF programs, it is:

(a) The first of the month in which the benefit group meets all program eligibility criteria and the Department receives the required verification; or

(b) The first of the month in which the Low Income Subsidy (LIS) information is received by the Social Security Administration (SSA), if the SMB or SMF program application was generated by the electronic transmission of LIS data from the SSA and the benefit group meets all program eligibility criteria.

(8) Retroactive eligibility is authorized under certain circumstances in some medical programs (see paragraph (3)(a)(A) of this rule, OAR 461-135-0875, and 461-180-0140).

Stat. Auth.: ORS 409.010, 409.050, 411.060, 411.070, 411.404, 411.704, 411.706, 414.025, 414.231, 414.826, 414.831, 414.839

Stats. Implemented: ORS 409.010, 409.050, 411.060, 411.070, 411.404, 411.704, 411.706, 414.025, 414.231, 414.826, 414.831, 414.839

Hist.: AFS 80-1989, f. 12-21-89, cert. ef. 2-1-90; AFS 20-1990, f. 8-17-90, cert. ef. 9-1-90; AFS 13-1991, f. & cert. ef. 7-1-91; AFS 1-1993, f. & cert. ef. 2-1-93; AFS 2-1994, f. & cert. ef. 2-1-94; AFS 10-1995, f. 3-30-95, cert. ef. 4-1-95; AFS 5-2000, f. 2-29-00, cert. ef. 3-1-00; SSP 5-2003, f. 2-26-03, cert. ef. 3-1-03; SSP 23-2003, f. & cert. ef. 10-1-03; SSP 17-2004, f. & cert. ef. 7-1-04; SSP 24-2004, f. 12-30-04, cert. ef. 1-1-05; SSP 7-2005, f. & cert. ef. 7-1-05; SSP 15-2006, f. 12-29-06, cert. ef. 1-1-07; SSP 10-2007, f. & cert. ef. 10-1-07; SSP 26-2008, f. 12-31-08, cert. ef. 1-1-09; 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 39-2009(Temp), f. 12-31-09, cert. ef. 1-1-10 thru 6-30-10; SSP 1-2010(Temp), f. & cert. ef. 1-26-10 thru 6-30-10; SSP 18-2010, f. & cert. ef. 7-1-10; SSP 20-2010(Temp), f. & cert. ef. 7-1-10 thru 12-28-10; SSP 32-2010, f. & cert. ef. 10-1-10; SSP 19-2013(Temp), f. 7-31-13, cert. ef. 8-1-13 thru 1-28-14

Notes
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