OAR 410-200-0455: Specific Requirements - Young Adults with Special Health Care Needs

In addition to the other eligibility requirements applicable to the Young Adults with Special Health Care Needs (YSHCN) program as set forth elsewhere within Chapter 410, including Division 200, this rule describes the specific eligibility requirements for the YSHCN program. (1) The YSHCN program provides OHP Plus coverage and supplementary benefits for individuals who meet the eligibility criteria, as follows: (a) For individuals who are not eligible for an OHP Plus-level HSD Medical program under OAR 410-200-0015(47)(d) or 410-200-0015(47)(f)(A)-(E) or Oregon Supplemental Income Program Medical (OSIPM) program under OAR 461-101-0010(18), YSHCN provides full OHP Plus coverage as described in OAR 410-120-1210(4)(g)(A) as well as supplemental benefits described in OAR 410-120-1210(4)(g)(A)-(C). (b) For individuals who are eligible for an OHP Plus-level HSD Medical program under OAR 410-200-0015(47)(d) or 410-200-0015(47)(f)(A)-(E) or OSIPM program under OAR 461-101-0010(18), YSHCN provides supplemental benefits described in OAR 410-120-1210(4)(g)(A)-(C). (2) To be eligible for the YSHCN program, an individual must meet the following criteria: (a) Meet the age requirement: (A) For dates of request or redeterminations during the 2025 calendar year: (i) Be 19 or 20 years of age in the month of their date of request or redetermination; or (ii) Be eligible for and receiving YSHCN coverage at the time they turn 21 years of age. (B) For dates of request or redeterminations during the 2026 calendar year: (i) Be 19, 20 or 21 years of age in the month of their date of request or redetermination; or (ii) Be eligible for and receiving YSHCN coverage at the time they turn 22 years of age. (b) Meet the financial requirement: (A) Be eligible for a MAGI Medicaid/CHIP program as defined in OAR 410-200-0015(47)(d) or 410-200-0015(47)(f)(A)-(E) or an OSIPM program as defined in OAR 461-101-0010(18); or (B) Have MAGI-based household income under 200 percent (200%) of the federal poverty level (OAR 410-200-0315) for the applicable family size. (c) Meet at least one (1) of the following non-financial health-related criteria: (A) Be identified as having a "complex chronic" condition or conditions based on the Pediatric Medical Complexity Algorithm (PMCA), which is found at the following URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4035595/; (B) Have a serious emotional disturbance or serious mental health issue as defined by an OHA-approved list of behavioral health diagnoses; (C) Be eligible for services due to an intellectual or developmental disability, as described in OAR 411-320-0080, on or after turning 16 years of age; or (D) Meet at least two (2) of the six (6) categories represented in the YSHCN eligibility screening questions as follows: (i) Receives or requires prescription medication for a physical, behavioral, developmental, emotional, or mental health condition which has lasted, or is expected to last, at least one (1) year and began before the individual was aged 19; (ii) Often uses or often needs medical care, mental health, or other health services for a physical, behavioral, developmental, emotional, or mental health condition which has lasted, or is expected to last, at least one (1) year and began before the individual was aged 19; (iii) Needs assistance to perform everyday activities due to a physical, behavioral, developmental, emotional, or mental health condition which has lasted, or is expected to last, at least one (1) year and began before the individual was aged 19; (iv) Receives or needs treatment or counseling for a mental health, substance use, or emotional condition which has lasted, or is expected to last, at least one (1) year and began before the individual was aged 19; (v) Often uses or often needs medical therapies, excluding counseling or talk therapy, for a physical, behavioral, developmental, emotional, or mental health condition which has lasted, or is expected to last, at least one (1) year and began before the individual was aged 19; or (vi) Often uses or often needs medical equipment or assistive devices due to a physical, behavioral, developmental, emotional, or mental health condition which has lasted, or is expected to last, at least one (1) year and began before the individual was aged 19. (3) The health-related qualifications for YSHCN non-financial eligibility described in section (2)(c) of this rule shall be reassessed as described below based on the method by which eligibility was initially determined as follows: (a) For YSHCN beneficiaries who were determined eligible based on the Pediatric Medical Complexity Algorithm (PMCA) described in section (2)(c)(A) of this rule, at each renewal, the Agency shall review submitted claims to confirm whether the individual has continued to receive care for the qualifying condition within the prior three (3) years. The Agency will: (A) Continue YSHCN eligibility for the individual after confirming that the individual has sought care or services for their qualifying condition within the prior three (3) years, and as long as all other eligibility conditions are met; or (B) Disenroll the individual from YSHCN after confirming that the individual has not sought care or services for their qualifying condition within the prior three (3) years. (b) For YSHCN beneficiaries who were determined eligible based on a qualifying behavioral health diagnosis as described in sections (2)(c)(B) of this rule, at renewal, the Agency shall review submitted claims to confirm whether the individual has continued to receive care for the qualifying condition within the prior two (2) years. The Agency shall: (A) Continue YSHCN eligibility for the individual after confirming that the individual has sought care or services for their qualifying condition within the prior two (2) years, and as long as all other eligibility conditions are met; or (B) Disenroll the individual from YSHCN after confirming that the individual has not sought care or services for their qualifying condition within the prior two (2) years. (c) For YSHCN beneficiaries who were determined eligible based on the YSHCN eligibility screening questions described in section (2)(c)(D), the screening must be performed at least every two (2) years at renewal. If the individual meets at least two (2) of the six (6) categories represented in the screening, this requirement is considered met when eligibility is evaluated. [ED. NOTE: To view attachments referenced in rule text, click here to view rule.]