The requirements of this rule apply to all Health Systems Division Medical Programs except for the OHP Bridge – Basic Health Program, Compact of Free Association (COFA) Dental Program, and Veteran Dental Program.

1. (1)  As a condition of eligibility, the applicant, beneficiary, or person legally responsible for the applicant or beneficiary must cooperate with the Agency to:

   1. (a) Identify any third party liable or potentially liable for medical costs paid by the Agency, Coordinated Care Organization (CCO), or prepaid managed care health services organization to, or on behalf of, an individual or any individual applying for or receiving medical assistance;
   2. (b) Provide information about liability of third parties or other insurance that may cover or pay for medical costs paid by the Agency, CCO, or prepaid managed care health services organization to or on behalf of a medical assistance applicant or recipient;
   3. (c) Provide other information as required by the CCO or prepaid managed care health services organization to assist in pursuing payment from any third party who may be liable for medical costs paid by the Agency, CCO, or prepaid managed care health services organization to or on behalf of a medical assistance applicant or recipient;
   4. (d) Comply with the personal injury claim provisions in accordance with OAR 461-195-0303 and 461-195-0310.

2. (2) As a condition of eligibility, the applicant, beneficiary, or person legally responsible for the applicant or beneficiary must cooperate with the Agency to assign their rights to third party payments as follows:

   1. (a) Assign to the Agency any rights of each household member receiving benefits to reimbursement for medical care costs to the Agency including any third party payments for medical care and any medical care support available under an order of a court or an administrative agency;
   2. (b) Assign to the Agency any rights to payment for medical care from any third party and, once they receive assistance, to assist the Agency in pursuing any third party who may be liable for medical care or services paid by the Agency, including health services paid for pursuant to ORS 414.706 to 414.774 as set forth in OAR 461-195-0303 and 461-195-0310; and

   3. (c) Except for eligibility granted under Healthier Oregon (OAR 410-200-0240) or during a period of Hospital Presumptive Eligibility (OAR 410-200-0105):

      1. (A) An applicant shall assign to the state the right of any Medicaid-eligible individual in the household to receive any cash medical support that accrues while the individual receives assistance, not to exceed the total amount of assistance paid; and
      2. (B) Cash medical support received by the Agency shall be retained as necessary to reimburse the Agency for medical assistance payments made on behalf of an individual with respect to whom such assignment was executed.
      3. (C) Each caretaker who is legally able shall assist the Agency and the Oregon Child Support Program (OCSP) in establishing paternity for each child receiving medical assistance and in obtaining an order directing the non-custodial parent of a child receiving benefits to provide cash medical support or health care coverage for that child
3. (3) The signature of the applicant, person legally responsible for the applicant, or authorized representative on the application for assistance signifies the applicant’s agreement to cooperate with the Agency and assign the rights to reimbursement for medical care costs to the Agency.
4. (4) To the extent that payment for covered expenses has been made under the state medical assistance program for health care items or services furnished to an individual, in any case where a third party has a legal liability to make payments, the state is considered to have acquired the rights of the individual to payment by any other party for those health care items or services. This assignment of rights is automatic in accordance with ORS 659.830 and 743B.470 and does not require the consent of any individual.

5. (5) The individual who is legally able to cooperate and assign rights, including a caretaker who has the authority to cooperate and assign rights on behalf of a child applying for or receiving Medicaid/CHIP and fails to do so, is ineligible for assistance until the requirements of this rule are met or unless good cause exists. An individual is considered to have good cause if any of the following are true:

   1. (a) Cooperation may result in emotional or physical harm;
   2. (b) Other good cause reasons exist; or

   3. (c) In addition to subsections (5)(a) and (5)(b), for individuals with the legal authority to pursue child support on behalf of a child who is applying for or receiving Medicaid benefits:

      1. (A) The child was conceived as a result of incest or rape and efforts to obtain support may be detrimental to the child.
      2. (B) Legal proceedings are pending for adoption of the child;
      3. (C) The parent is being helped by a public or licensed private social agency to resolve the issue of whether to release the child for adoption; or
      4. (D) The individual is pregnant.

Statutory/Other Authority

ORS 411.402, 411.404, 413.042, 411.060, 411.033, 411.034 & 411.085

Statutes/Other Implemented

ORS 411.402, 411.404, 411.406, 413.032, 414.025, 414.231, 414.706, 411.400, 416.510, 416.520 & 416.530

History

DMAP 63-2025, amend filed 08/28/2025, effective 09/01/2025
DMAP 46-2025, temporary amend filed 06/02/2025, effective 06/03/2025 through 11/29/2025
DMAP 23-2020, amend filed 05/07/2020, effective 05/08/2020
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