1. (1) A resident of a public institution is not eligible for Health System Division (HSD) Medical Program benefits, except as follows:

   1. (a) For individuals residing in an Institution for Mental Disease (IMD), including the Oregon State Hospital, who are:

      1. (A) Under age 21;
      2. (B) Age 21 if they were admitted to the IMD before their 21st birthday; or
      3. (C) Age 65 or older.
   2. (b) Residents of a public institution may be eligible for OHP Bridge – Basic Health Program benefits if they are awaiting disposition of charges.

2. (2) For all individuals enrolled in HSD Medical Programs except for OHP Bridge – Basic Health Program who become a resident of a public institution, benefits shall be suspended for the duration of the period in which the individual is a resident of that institution.

   1. (a) The effective date of the suspension of benefits is the day following the date on which an individual becomes a resident of a public institution.

   2. (b) Except as described in section (2)(c) of this rule, suspended benefits shall be reinstated to the same level of coverage the individual was receiving when they became a resident of a public institution effective the date on which an individual ceases to be a resident of a public institution without the need for a new application when:

      1. (A) The Agency learns the individual is no longer a resident of a public institution within the twelve (12) calendar months following the date on which the change occurred; or
      2. (B) The individual leaves the public institution to be admitted to a medical facility as an inpatient with an expected stay of at least 24 hours, provided the medical facility is not associated with the public institution where the individual is a resident.
   3. (c) Individuals who were in the YSHCN program when they became a resident of a public institution and who have turned age 26 on or prior to their release date shall not have the supplemental YSHCN benefits described in OAR 410-200-0455(2)(a) and (b) reinstated upon their release.
   4. (d) Once benefits are reinstated as described in subsection (2)(b) of this rule, a redetermination of eligibility shall be processed unless benefits are restored on a case where the existing renewal date is more than two (2) calendar months beyond the month in which the action is being taken.
3. (3) For individuals enrolled in OHP Bridge – Basic Health Program who become a resident of a public institution, benefits shall be terminated effective the day following the day on which they became a resident of a public institution except that coverage shall be maintained while the individual’s charges are pending disposition. In order to regain eligibility for OHP Bridge-Basic Health Program following release from the public institution, the individual must reapply.

Statutory/Other Authority

ORS 411.095, 411.402, 411.404, 413.038, 414.025 & 414.534

Statutes/Other Implemented

ORS 411.070, 411.404, 411.439, 411.443, 411.445, 411.816, 412.014, 412.049 & 414.426

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 12-2023, amend filed 03/30/2023, effective 04/01/2023
DMAP 67-2020, amend filed 12/22/2020, effective 01/01/2021
DMAP 33-2020, temporary amend filed 06/29/2020, effective 07/06/2020 through 01/01/2021
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
DMAP 25-2018, amend filed 05/01/2018, effective 05/01/2018
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