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OREGON YOUTH AUTHORITY

 

DIVISION 610

TITLE XIX AND GENERAL ASSISTANCE

MEDICAL ELIGIBILITY

 

416-610-0000

Purpose and Scope

The purpose of these rules is to set forth procedures and criteria which the Oregon Youth Authority will use to make Title XIX medical eligibility determinations for youth in substitute care who are in the care and custody of Oregon Youth Authority, and to make such determinations for those youth who do not meet the financial eligibility criteria for Title XIX who would otherwise be eligible for the General Assistance Medical Program. Both of these programs are administered by the Office of Medical Assistance Programs. (ORS 418.005)

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

 

416-610-0010

Definitions

As used in this Division, the following definitions apply:

(1) "AFS": Adult and Family Services Division.

(2) "Assistance Standards": Amount of entitlement determined by AFS taking into consideration the need for food, shelter, utilities, clothing, personal incidentals and household supplies. Need is determined for individuals by comparing available income and resources to the ADC assistance standards.

(3) "Custody": Legal custody and guardianship, as defined in ORS 419.519 and 419.521.

(4) "Earned Income": Income received from earnings of the youth who is either working full time or part time.

(5) "Full-Time Employment": 160 hours per month.

(6) "Full-Time School Attendance": Number of hours as defined by each individual school.

(7) "G.A.": General Assistance with no federal match.

(8) "Paid Substitute Care": Oregon Youth Authority is making a payment on behalf of the child.

(9) "Resources": All real and personal property, automobiles, life insurance and trusts, including cash, savings, checking accounts or trust and agency (T&A) accounts.

(10) "OYA": Oregon Youth Authority.

(11) "Unearned Income": Refers to income to the youth in the youth's own right, such as Social Security benefits, Veteran's benefits, child support payments or other entitlements. It does not include the OYA foster care payment.

(12) "OMAP (Office of Medical Assistance Programs)": Refers to the official state Title XIX (Medicaid) agency located in the Office of the Director, DHR. Most DHR - wide Title XIX functions are handled by OMAP, but a few functions are retained by AFS. OMAP was formerly a part of AFS.

(13) "Spend Down": Refers to the use of excess monthly income over the AFS assistance standard that is used to pay for medical expenses which enables a client to be Title XIX eligible. (ORS 418.005)

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

 

416-610-0020

Title XIX Policy Determinations Required

(1) Each youth in substitute care whose care is paid by OYA or another public agency must have a determination of Title XIX eligibility before the issuance of a medical care ID card is authorized by OYA. Eligibility will not be presumed. In order to determine this eligibility the form "Individual Eligibility Determination for Title XIX Medical Coverage" must be completed, dated, signed by either a OYA worker or their designee, and filed in the youth's case record. The following youth are potential candidates for Title XIX coverage:

(a) Youth in shelter or foster home placements or, in a licensed child care agency, group home, or residential care placement, or a non-profit public drug and alcohol treatment facility;

(b) Youth in placements listed above when the care is paid by another public agency including county juvenile departments.

(2) Youth admitted to the hospital prior to entering substitute care or newborns released from the hospital into substitute care. Title XIX eligibility is effective the date that OYA obtains custody of the child and the child is determined eligible.

(3) Youth on runaway status who would otherwise be in care. Eligibility for Title XIX resumes at the time they are located as long as OYA retains custody and the youth would continue to be in substitute care and Title XIX eligible if not on runaway status. OYA is not responsible for medical bills incurred while a youth is on the run if the youth is not replaced in care.

(4) Youth in subsidized Independent Living.

(5) Youth receiving SSI. An application for Title XIX must be completed to establish initial eligibility. (ORS 418.005)

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

 

416-610-0030

Eligibility Factors Assistance Standard

(1) In order to be eligible for Title XIX coverage while in foster care, a child must meet the income level in one of five ways:

(a) Through the ADC payment standard for one in a household of one, or (AFS Rule 461-004-0915);

(b) Through the Medically Needy standard for one in a household of one;

(c) Through the Medically Needy with spend-down standard;

(d) Eligible for and receiving Title IV-E foster care payments;

(e) Receiving (SSI) Supplemental Security Income.

(2) Unearned Income: All unearned income that the child is entitled to receive must be counted in determining Title XIX eligibility. Income must be used to determine eligibility even if the agency has not begun to receive the benefits as long as that income has been awarded to the child. (ORS 418.005)

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

 

416-610-0040

Earned Income

Treatment of earned income in determining eligibility for Title XIX will be handled solely on the basis of the child's student status as follows:

(1) The following youth will have their earnings disregarded:

(a) Full-time students (as defined by the school) attending grade 12 or below, or attending a course of vocational or technical training, or GED classes in lieu of high school or planning to return to school or vocational training; or

(b) Part-time students who are not employed full time and are attending grade 12 or below, or attending an equivalent level of vocational or technical training or GED classes, or planning to return to school or training;

(c) Youth earning income under the Job Training Partnership Act (JTPA) programs (except Job Corps payments).

(2) A youth who is attending school part-time and employed full-time, or not attending school will have his/her earnings partially disregarded. The first $90 of earned income will be disregarded. The earnings will be computed on an OYA form to determine the youth's eligibility for Title XIX. (ORS 418.005)

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

416-610-0050

Resources

(1) Total resources for a youth may not exceed $2,000 in order to be eligible for Title XIX. If a youth has a motor vehicle, the first $1,500 of equity value of that vehicle is exempt. The equity value over $1,500 will be counted towards the $2,000 resource limitation.

(2) Youth receiving SSI are always eligible for Title XIX. If the youth's assets (OYA Trust Account) exceed the limitation for SSI eligibility, it must be reported to the Social Security Administration.

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

416-610-0060

Citizenship and Alienage

(1) To be eligible for Title XIX the child must be:

(a) A United States citizen; or

(b) An alien lawfully admitted under provisions of Section 203(a) (7) before April 1980, 207(c), 208, 249, 584(a), 101, Section 207(c) (after March 31, 1980) or Section 212(d) (5) of the Immigration and Nationality Act as a paroled or conditional entrant; or aliens granted immigrant status according to the Amerasian Homecoming Act;

(c) An amnesty alien with permanent or unexpired temporary status admitted under Section 245A, 210, or 210A of the Immigration and Nationality Act.

(2) In order to authorize benefits, there must be proof that a youth is a U.S. citizen, or in the country legally. Birth certificates, or citizenship papers, alien registration cards, permanent visas, Cuban and Refugee registration cards may be used.

(3) To authorize Title XIX benefits, there must be proof that the youth is in the country legally. Individuals completing and signing the OYA application swear that they have reported the youth's citizenship honestly. (ORS 418.005)

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

416-610-0070

Social Security Number

The youth must have a social security number (SSN) or verification that an application for an SSN has been made. When a youth does not have an SSN, verification of application for the social security number must be documented in the case file. (ORS 418.005)

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

416-610-0080

Retroactive Eligibility

Children receiving GA medical due solely to the lack of an SSN are eligible for Title XIX retroactive to the date of placement once verification of an application for an SSN from the Social Security Administration has been obtained. An AFS 148 form titled "Recipient Subsystem, Claims Processing, Addition/Correction" must be completed on each case and sent to the Client Maintenance Section, AFS, P.O. Box 17150, Salem, OR 97305, for retroactive claiming of Title XIX. Title XIX eligibility retroactive to the date of placement must also be entered into the OYA Information System. (ORS 418.005)

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

 

416-610-0090

Assignment of Medical Benefits

(1) All known or potential health insurance benefits or resources and all other third-party medical benefits, including casualty insurance available to the child, must be assigned to the Adult and Family Services Division.

(2) The worker, or their designee as guardian of the child, may sign the OYA form assigning these benefits.

(3) An AFS 415-H, "Medical Resource Report Form," must be completed and sent to AFS, Recovery Resource Section, P.O. Box 14023, Salem, OR 97309, for every child with health insurance coverage. If the child is covered by private health insurance such as Kaiser or another Health Maintenance Organization plan or Physician Care Organization (HMO/PCO), and is placed outside of a 30-mile radius, a statement of "accident injury policy only" must be written in the comment section of the AFS 415-H form. This exception statement will allow the foster parents the freedom to obtain medical care for the youth within their local area.

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

 

416-610-0100

Lump Sum Benefits

If all or part of a lump sum (any income received as a one-time payment) is spent during the month it is received in OYA, Accounting Services, so that the ending Trust and Agency balance is less than the Medically Needy resource limit of $2,000, Title XIX medical eligibility may continue. (ORS 418.005)

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

416-610-0110

Title XIX Coverage

If a youth leaves paid substitute care, Title XIX eligibility exists for the remainder of the calendar month the youth was in care as long as the youth was eligible the day the medical card was issued. (ORS 418.005)

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

416-610-0120

Reviews

(1) Each youth's eligibility for Title XIX must be reviewed every 12 months unless the youth is receiving SSI. A review is not required for a youth receiving SSI unless the SSI is terminated.

(2) When there is a change in income or resources, the OYA form must be completed in the month the change occurs in order to update the medical eligibility for the following month.

(3) When it has been determined that a youth was incorrectly shown as Title XIX eligible for prior months, an AFS 148 will be completed to retroactively correct the youth's computer file. (ORS 418.005)

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

416-610-0130

Cooperation with AFS Quality Control

(1) As the State Title XIX agency, DHR is responsible to review cases covered by these rules for compliance with federal law and regulations. AFS performs this function.

(2) All cases to be reviewed will be requested through the OYA Financial Resource Unit. All case material (eligibility and service records) will be forwarded by OYA to AFS upon request. The cases will be selected for review by a systematic random sample each month from a universal listing of Title XIX-eligible cases. Title IV-E cases are not included in cases to be reviewed. (ORS 418.005)

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

416-610-0140

GA Medical Policy

(1) All youth in paid substitute care who do not meet the eligibility requirements for Title XIX, will be eligible for General Assistance(GA) medical through OMAP.

(2) An OYA form will reflect eligibility for GA medical when it has been determined there is no eligibility for Title XIX. These cases will be reviewed every 12 months in order to determine possible change in income and/or resources which may change the youth's eligibility for Title XIX.

(3) Infrequently a non-relative foster care provider is the designated payee for a foster child's benefits. Until payee status is transferred to the agency and a foster care maintenance payment is made, the youth is eligible for GA medical as long as their income is less than the standard cost of foster care for their age level.

(4) Youth in non-subsidized Independent Living are eligible for GA medical unless their income exceeds the standard cost of foster care for their age level. (ORS 418.005)

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

416-610-0150

Non-paid Relative Placements

(1) Youth living with relatives in non-paid care and living in the state must be referred to AFS for a cash grant and/or Title XIX coverage. OYA cannot issue a GA medical card to youth in non-paid relative care. The worker will advise the family to pursue medical coverage for the youth through AFS.

(2) A youth placed in a relative's home out-of-state will be referred to the Title XIX agency in that state for a Title XIX determination. If that state determines there is no Title XIX eligibility, OYA may issue a GA medical card only when the youth's income is below the foster care rate. (ORS 418.005)

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

416-610-0160

Title XIX Eligibility Under COBRA For Out-of-State Placements

(1) The Consolidated Omnibus Reconciliation Act (COBRA) of 1985 provides for Title XIX coverage in the state of residence for youth receiving Title IV-E foster care payments.

(2) All youth receiving Title IV-E foster care payments from other states moving to the State of Oregon must be referred to the AFS office in the county of residence for a Title XIX eligibility determination. Under no circumstances is OYA to authorize the issuance of a Medical Care Identification (MCI) for youth in the custody of another state. In addition, all youth who are Title IV-E eligible in Oregon and move to another state are eligible for Title XIX in the state of residence. The MCI will be issued by the state of residence.

(3) Youth receiving SSI payments and moving outside the State of Oregon are eligible for Title XIX in their state of residence. (ORS 418.005)

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

416-610-0170

Children in Custody of County Juvenile Departments

(1) Youth in the care and custody of the County Juvenile court in a substitute care placement may be eligible for Title XIX coverage from OMAP. County Juvenile Departments will submit applications to the Financial Resource Unit for Title XIX eligibility determinations. Approved applications will be forwarded to AFS. If a youth is not eligible for Title XIX, he/she is not eligible for any medical coverage through OMAP.

(2) To be eligible for Title XIX coverage from AFS, the youth must:

(a) Be under 21 years of age; and

(b) Have income less than the ADC Medically Needy (no spend down) payment standard for one person; and

(c) Be placed in a shelter, foster, group home or residential treatment facility, or in a subsidized Independent Living Program. (ORS 418.005)

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

416-610-0180

Youth in Close Custody

Youth held in a county or state juvenile detention facility or under arrest and/or in official custody are ineligible for Title XIX or GA medical coverage. Payment for emergency medical services only for youth in close custody and OYA custody may be made from the OYA "Other Medical" budget. (ORS 418.005)

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

416-610-0190

Youth in Residential Care with Payment by Another Public Agency

(1) Youth in substitute care approved by a public agency of this state, and for whom a public agency of this state is assuming some financial responsibility, may be eligible for medical coverage.

(2) Youth in the care and custody of OYA and placed in residential care paid by another public agency whose income does not exceed the ADC Medically Needy (no spend down) payment standard for one person may be eligible for Title XIX. Others will be eligible for GA medical coverage.

(3) To issue medical care identification to youth in the care and custody of OYA and in non-paid residential care funded by another public agency, the following must be entered on the OYA Information System:

(a) Medical eligibility after completion of a CSD 190;

(b) An SRES non-pay service;

(c) The youth's address (ORS 418.005).

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

416-610-0200

Temporary Medical Card Issuance

The AFS-1086, "Temporary Medical Care Identification Card (MCIC)", may be issued when a youth requires medical care prior to receiving the computer generated MCIC (Medical Care Identification Card, OMAP 1417). The temporary MCIC may also be issued when the youth is placed, moved to a new placement, or when the MCIC is lost and medical care is needed before a new card will be issued. (The eligibility data must be entered into the system at the time of issuance in order for the provider to be paid.) (ORS 418.005)

Stat. Auth.: OL Ch. 422, 1995
Stats. Implemented: OL Ch. 422, 1995
Hist.: OYA 2-1995, f. 12-19-95, cert. ef. 1-2-96

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