With the exception of OHP Bridge - Basic Medicaid and YSHCN, this rule sets out when an individual is presumptively eligible for MAGI Medicaid/CHIP, BCCTP, and FFCYM (OAR 410-200-0407) based on the determination of a qualified hospital. In addition, presumptive eligibility for OHP Bridge Basic Health Program cannot be established based on the determination of a qualified hospital.

1. (1) A qualified hospital shall, with the consent of the individual or someone acting on the individual’s behalf, determine Hospital Presumptive Eligibility (HPE) for MAGI Medicaid/CHIP, BCCTP, or FFCYM.

2. (2) The qualified hospital shall determine Hospital Presumptive Eligibility based on the following information attested by the individual:

   1. (a) Family size;
   2. (b) Household income;
   3. (c) Receipt of other health coverage;
   4. (d) Residency
   5. (e) US citizenship, US national, or non-citizen status.

3. (3) To be eligible via Hospital Presumptive Eligibility, an individual must be a US citizen, US National, or meet the citizenship and non-citizen status requirements found in OAR 410-200-0215 and one of the following:

   1. (a) A child under the age of 19 with income at or below 300 percent of the federal poverty level;
   2. (b) A parent or caretaker relative of a dependent child with income at or below the MAGI Parent or Caretaker Relative income standard for the appropriate family size in OAR 410-200-0315;
   3. (c) A pregnant individual with income at or below 185 percent of the federal poverty level;
   4. (d) A non-pregnant adult between the ages of 19 through 64 with income at or below 133 percent of the federal poverty level; or
   5. (e) An individual under the age of 65 who has been screened by a licensed healthcare provider and determined to need treatment for breast or cervical cancer, or who has been determined eligible for the Breast and Cervical Cancer Treatment Program (OAR 410-200-0400);
   6. (f) An individual under the age of 26 who was in Oregon foster care on their 18th birthday.

4. (4) To be eligible via Hospital Presumptive Eligibility, an individual may not:

   1. (a) Be receiving Supplemental Security Income benefits;
   2. (b) Be a Medicaid/CHIP beneficiary; or
   3. (c) Have received a Hospital Presumptive Eligibility approval start date within the year (365 days) prior to a new Hospital Presumptive Eligibility period start date.

5. (5) In addition to the requirements outlined in sections (3) and (4) above, the following requirements also apply:

   1. (a) To receive MAGI Adult benefits via Hospital Presumptive Eligibility, an individual may not be entitled to or enrolled in Medicare benefits under part A or B of Title XVIII of the Act;
   2. (b) To receive MAGI CHIP benefits via Hospital Presumptive Eligibility, an individual may not be covered by any minimum essential coverage that is accessible (OAR 410-200-0410(2)(c));
   3. (c) To receive BCCTP benefits via Hospital Presumptive Eligibility, an individual may not be covered by any minimum essential coverage.

6. (6) The Hospital Presumptive Eligibility period begins on the earlier of:

   1. (a) The date the qualified hospital determines the individual is eligible; or
   2. (b) The date that the individual received a covered medical service from the qualified hospital, if the hospital determines the individual is eligible and submits the decision to the Authority within five (5) calendar days following the date of service.

7. (7) The Hospital Presumptive Eligibility period ends:

   1. (a) For individuals on whose behalf a Medicaid/CHIP application has been filed by the last day of the month following the month in which the hospital presumptive eligibility period begins, the day on which the state makes an eligibility determination for MAGI Medicaid/CHIP and sends basic decision notice; or
   2. (b) If subsection (7)(a) is not completed, the last day of the month following the month in which the hospital presumptive eligibility period begins.

8. (8) A Hospital Presumptive Eligibility approval is not a full eligibility determination and does not entitle beneficiaries to the following:

   1. (a) A child is not entitled to continuous eligibility (OAR 410-200-0135) based solely on the receipt of benefits during a period of Hospital Presumptive Eligibility;
   2. (b) A baby born to an individual receiving benefits during a period of hospital presumptive eligibility is not assumed eligible (OAR 410-200-0135) based solely the Hospital Presumptive Eligibility determination of the parent;
   3. (c) An individual is not entitled to EXT (OAR 410-200-0440) based solely on the receipt of MAGI PCR during a period of Hospital Presumptive Eligibility;
   4. (d) An individual is not entitled to receive YSHCN benefits as described in OAR 410-200-0455;
   5. (e) An individual whose Hospital Presumptive Eligibility period is terminated due to incarceration is not entitled to automatic restoration of benefits upon release (OAR 410-200-0140);
   6. (f) Individuals are not entitled to hearing rights (OAR 410-200-0145) for benefits received during a period of Hospital Presumptive Eligibility.

Statutory/Other Authority

ORS 411.402, 411.404, 413.042 & 414.534

Statutes/Other Implemented

ORS 411.400, 411.402, 411.404, 411.406, 411.439, 411.443, 413.032, 413.038, 414.025, 414.231, 414.447, 414.534, 414.536, 414.706 & 414.241

History

DMAP 138-2024, amend filed 11/26/2024, effective 01/01/2025
DMAP 94-2024, amend filed 05/29/2024, effective 06/01/2024
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 24-2016, f. & cert. ef. 6-2-16
DMAP 78-2015(Temp), f. & cert. ef. 12-22-15 thru 6-18-16
DMAP 3-2015, f. & cert. ef. 1-30-15
DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15
DMAP 20-2014, f. & cert. ef. 3-28-14
DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14
DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14