OAR 461-135-0950: Eligibility for Residents of Public Institutions

(1) This rule sets out additional restrictions on the eligibility of residents of public institutions for programs covered by Chapter 461 of the Oregon Administrative Rules. (2) Definition of a "resident of a public institution". (a) An individual living in a public institution (see section (3) of this rule) who is: (A) Confined involuntarily in a local, state or federal prison, jail, detention facility, or other penal facility, including an individual being held involuntarily in a detention center awaiting trial or an individual serving a sentence for a criminal offense; (B) Residing involuntarily in a facility under a contract between the facility and a public institution where, under the terms of the contract, the facility is a public institution ; (C) Residing involuntarily in a facility that is under governmental control; (D) Receiving care as an outpatient while residing involuntarily in a public institution ; or (E) In the OSIPM and QMB programs, no longer a resident of the public institution during a temporary period of hospitalization in a medical institution outside of the correctional facility. (b) An individual is not considered a resident of a public institution when: (A) The individual is released on parole, probation, or post-prison supervision; (B) The individual is on home- or work-release, unless the individual is required to report to a public institution for an overnight stay; (C) The individual is voluntarily residing in a supervised community residential facility and all of the following are true: (i) Residents are not precluded from working outside the facility in employment available to individuals who are not under justice system supervision; (ii) Residents can use community resources such as libraries, grocery stores, recreation and education at will, notwithstanding any house rules such as a requirement to sign in and out, curfews, or hours during which the residence is closed or locked; and (iii) Residents can seek health care treatment in the broader community to the same or similar extent as other Medicaid enrollees in the state. (D) The individual is staying voluntarily in a detention center, jail, or county penal facility after their case has been adjudicated and while other living arrangements are being made for the individual; or (E) The individual is in a public institution pending other arrangements as defined in 42 CFR 435.1010. (3) A "public institution" is any of the following: (a) A “state hospital” (see ORS 162.135). (b) A local correctional facility (see ORS 169.005): a jail or prison for the reception and confinement of individuals that is provided, maintained and operated by a county or city and holds individuals for more than 36 hours. (c) A Department of Corrections institution (see ORS 421.005): a facility used for the incarceration of individuals sentenced to the custody of the Department of Corrections, including a satellite, camp, or branch of a facility. (d) A youth correction facility (see ORS 162.135): (A) A facility used for the confinement of individuals placed in the legal or physical custody of the youth authority, including a secure regional youth facility, a regional accountability camp, a residential academy and satellite, and camps and branches of those facilities; or (B) A facility established under ORS 419A.010 to 419A.020 and 419A.050 to 419A.063 for the detention of individuals pursuant to a judicial commitment or order. (4) Definition of serious mental illness. An individual has a serious mental illness if the individual has been diagnosed by a psychiatrist, a licensed clinical psychologist or a certified non-medical examiner as having dementia, schizophrenia, bipolar disorder, major depression or other affective disorder or psychotic mental disorder other than a substance abuse disorder and other than a disorder that is caused primarily by substance abuse. (5) An individual who resides in a state hospital (see subsection (3)(a) of this rule), meets the definition of having a serious mental illness (see section (4) of this rule), and applies for medical assistance between 90 and 120 days prior to the expected date of the person's release from the state hospital may be found eligible for medical assistance. If the individual is determined to be eligible, the effective date of the individual's medical assistance is the date the individual is no longer a resident of the institution. (6) In the OSIPM and QMB programs, except as provided for in section (7) of this rule, an individual who is at least 21 years of age and less than 65 years of age who becomes a resident of a state hospital has medical benefits suspended. When an individual with suspended medical benefits is no longer a resident of the state hospital , or when the individual is admitted to a medical institution outside of the state hospital for a period of hospitalization, medical benefits are reinstated effective the first day the individual is no longer a resident. (7) An individual residing in a state hospital may be eligible for OSIPM and QMB program benefits if the individual meets the requirements of one of the following subsections: (a) The individual is 65 years of age or older. (b) The individual receives a Certificate of Need for Services from the State-authorized agency, and meets one of the following: (A) The individual is under 21 years of age. (B) The individual is 21 years of age, received a Certificate of Need for Services from the State-authorized agency, and received those services immediately before reaching age 21. Except as provided for in subsection (a) of this section, eligibility ends at age 22. (8) For all programs covered under chapter 461 of the Oregon Administrative Rules: (a) Except as provided otherwise in this rule, a resident of a public institution (see section (2) of this rule) is not eligible for benefits. (b) Except as provided otherwise in this rule, if a pregnant individual receiving medical assistance through the OSIPM program becomes a resident of a public institution , their medical benefits are suspended. When the Department learns the individual is no longer a resident of a public institution , their medical benefits are reinstated – effective on the first day they are no longer a resident of a public institution – if they are still in their protected period of eligibility under OAR 461-135-0010. (c) If an individual receiving medical assistance through the OSIPM or QMB programs becomes a resident of a public institution at a correctional facility (see subsections (3)(b) through (3)(d) of this rule), medical benefits are suspended during the incarceration period. (d) In the OSIPM and QMB programs: (A) When the Department learns the individual is no longer a resident of a public institution within 12 calendar months of the change, suspended benefits may be restored , effective the first day the individual was no longer a resident of a public institution. (B) When the Department learns the individual has been admitted to a hospital outside of the public institution for a period of hospitalization, suspended benefits may be restored effective the first day of the period of hospitalization. (C) When the date benefits are reinstated is prior to the individual’s eligibility renewal date, the eligibility renewal date will be maintained. (D) When the date benefits are reinstated is after the individual’s eligibility renewal date, eligibility must be redetermined immediately after benefits are restored. (9) In the GA and SNAP programs, in addition to the other provisions of this rule, a resident of a public institution released from a public institution on home arrest and required to wear an electronic device to monitor their activity, is ineligible for benefits if the correctional agency provides room and board to the individual. (10) In the GA program, when an individual becomes a resident of a public institution : (a) Housing assistance payments may continue for one calendar month following the month the individual became a resident of a public institution if the following are true: (A) The Department can determine that the individual will no longer be a resident of a public institution before the end of the calendar month following the month the individual became a resident of a public institution , and (B) The individual’s housing arrangement is still available. (b) When the individual will no longer be a resident of a public institution after the end of the calendar month following the month the individual became a resident of a public institution , or when the date the individual will no longer be a resident of a public institution is not known, housing assistance payments will be closed effective the end of the notice period (see OAR 461-175-0050) for a timely continuing benefit decision notice (see OAR 461-001-0000).