OAR 410-200-0135: Assumed, Continuous, and Protected Eligibility

(1) Assumed Eligibility is as described below: (a) A child born to an individual who is eligible for and receiving Medicaid/Children’s Health Insurance Program (CHIP) benefits at the time of the birth is an assumed eligible newborn (AEN); (b) An AEN is eligible for MAGI Child benefits (OAR 410-200-0415) effective the date of birth through the end of the month in which the child turns one year of age, unless: (A) The child dies; (B) The child is no longer a resident of Oregon; or (C) The child’s representative requests a voluntary termination of the child’s eligibility. (c) A new application or request for coverage is not required for an AEN. (d) An AEN is entitled to assumed eligibility without providing a Social Security Number (SSN). An SSN is required to maintain coverage after the assumed eligibility period ends. (2) Continuous Eligibility, as described below, applies to all HSD Medical programs except the OHP Bridge – Basic Health Program (OAR 410-200-0438), Extended Medical Assistance (OAR 410-200-0440), Substitute Care (OAR 410-200-0405), and Breast and Cervical Cancer Treatment Program (OAR 410-200-0400). (a) The Continuous Eligibility (CE) period is the period of time an individual who is determined eligible for an HSD medical benefit shall maintain coverage despite changes in circumstance that may otherwise preclude eligibility, with consideration of exceptions described in section (2)(b). (b) Coverage may be terminated during the CE period in the following circumstances: (A) The individual is no longer an Oregon resident; (B) The individual dies; (C) The individual or someone authorized to act on their behalf requests voluntary termination of eligibility; (D) The agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of agency error or fraud, abuse, or perjury attributed to the individual or someone authorized to act on their behalf; (E) An assumed eligible newborn as described in section (1) of this rule, turns age 1, and no SSN has been provided; or (F) An individual reports a change to their Citizenship or Non-Citizen status and the information cannot be verified as outlined in OAR 410-200-0230 (2) (c) The CE period is established when an individual is determined eligible for HSD medical benefits with no outstanding requests for information, as follows: (A) At initial approval of eligibility, the CE period begins on the first of the month in which the individual established a Date of Request (DOR), or (B) When approved for renewal of eligibility, the new CE period begins on the first of the month following the renewal due date. (d) The length of the CE period is based on age and program eligibility, as follows: (A) Children under six (6) years of age are entitled to CE through the end of the month of their sixth (6) birthday or twenty-four (24) months, whichever is later. (B) Individuals age six (6) and above are entitled to twenty-four (24) months of CE. (e) Except for individuals in the YSHCN program who turn 26, benefits will not be reduced or terminated during an individual’s CE period. An individual receiving YSHCN program benefits will lose the supplemental benefits described in OAR 410-200-0455(2)(a) and (b) when they turn age 26, they shall maintain OHP Plus coverage for the remainder of their CE period. (f) If an individual’s eligibility is redetermined during the continuous eligibility period and they no longer meet: (A) Financial eligibility requirements for any HSD Medical Program of the same or better benefit, they shall retain coverage through the program with the uppermost income eligibility threshold for which the individual meets non-financial eligibility requirements; (B) Financial or non-financial eligibility requirements for any HSD Medical Program of the same or better benefit, they shall retain coverage through the Parent and Caretaker Relative program (OAR 410-200-0420). (3) Protected Eligibility is as described below: (a) Except for those individuals eligible for and receiving OHP Bridge – Basic Health Program benefits, individuals who are eligible for and receiving any HSD Medical Program benefits for any portion of their pregnancy are entitled to protected eligibility for the duration of the pregnancy and the postpartum eligibility period. (b) The postpartum eligibility period is: (A) Except as described in subsection (3)(b)(B), the postpartum eligibility period is twelve (12) calendar months following the month in which the pregnancy ends; (B) For individuals who do not meet the citizen and non-citizen status requirements, who are eligible for and receiving Citizenship Waived Medical (CWM) Plus coverage for any portion of their pregnancy, the postpartum eligibility period is the two (2) calendar months following the month in which the pregnancy ends. (c) Benefits may not be terminated or reduced during a period of protected eligibility unless: (A) The individual is no longer an Oregon resident; (B) The individual dies; (C) The individual or someone authorized to act on their behalf requests a voluntary termination of eligibility; or (D) The agency determines that eligibility was erroneously granted at the most recent determination, redetermination or renewal of eligibility because of agency error or fraud, abuse, or perjury attributed to the individual or someone authorized to act on their behalf.