Oregon Administrative Code

410-173-0040 Individually Based Limitations (1) When certain HCBS setting qualities may not be met due to a threat to the health and safety of an Individual or others, a provider shall submit a request for an Individually-based limitation (IBL) to the IQA; (2) An IBL shall be sup…

410-173-0045 Documentation Standards (1) Provider rendering HCBS are required to maintain records that fully support the extent of services for which payment is requested and provide the records to the Division or IQA upon request; (2) All records shall comply with documentation …

410-173-0050 HCBS Community Based Integrated Supports (1) Community-Based Integrated Supports (CBIS) are services and supports offered to Individuals that require assistance in the acquisition, retention, or improvement with life management, socialization skills and community eng…

410-173-0055 Eligibility Criteria for Community Based Integrated Supports (1) To be eligible for CBIS defined in this rule, Individuals shall: (a) Be eligible for 1915(i) HCBS as outlined in OAR 410-173-0010 (b) Have identified needs for assistance with ADLs or IADLs requiring se…

410-173-0060 HCBS Residential Habilitation (1) HCBS Residential Habilitation Services are designed to assist and support an Individual to maintain, reacquire, or improve skills and functioning in ADL and IADL due to the symptoms of a behavioral health condition; (2) HCBS Resident…

410-173-0065 Eligibility Criteria for HCBS Residential Habilitation (1) To be eligible for HCBS Residential Habilitation Services defined in this rule, Individuals shall: (a) Be eligible for 1915(i) HCBS per OAR 410-173-0010; (b) Have assessed needs for HCBS Residential Habilitat…

410-173-0070 HCBS Psychosocial Rehabilitation for Persons with Chronic Mental Illness (1) Psychosocial Rehabilitation (PSR) services shall be identified and agreed upon within the PCSP and shall: (a) Support the desires and goals of the Individual receiving services; (b) Increase…

410-173-0075 Eligibility Criteria for HCBS Psychosocial Rehabilitation for Persons with Chronic Mental Illness (1) To be eligible for PSR services outlined in these rules, Individuals shall: (a) Be eligible for 1915(i) HCBS as outlined in OAR 410-173-0010 and (b) Have assessed ne…

410-173-0080 Housing Support Services (1) HCBS Housing Support Services shall be provided to Individuals as determined medically necessary and appropriate for an Individual to obtain and reside in an independent community setting and are tailored to the goal of maintaining an Ind…

410-173-0085 Eligibility for Housing Support Services (1) To be eligible for Housing Support Services outlined in these rules, Individuals shall: (a) Be eligible for 1915(i) Housing Support Services be outlined in these rules or OAR 410-173-0010; (b) Have assessed needs for Housi…

410-173-0090 Home Delivered Meals (1) 1915(i) home delivered meals shall be provided to eligible Individuals who are home bound, live in their own home, and are unable to complete meal preparation, to assist an Individual to remain in their own home and are intended to provide on…

410-173-0095 Eligibility for Home Delivered Meals (1) To be eligible for 1915(i) home delivered meals and Individual must: (a) Be 1915(i) HCBS as outlined in OAR 410-173-0010 eligible; (b) Have assessed needs for Home Delivered Meals as documented and approved in the PCSP; (c) Be…

410-173-0100 Provider Qualifications for Home Delivered Meals (1) To be in alignment with the provision of services, home delivered meal providers must have contracts with, or be, an Area Agency on Aging or AAA as defined in 411-002-0100(1). (2) The provider must be in compliance…

410-173-0105 HCBS-In-Home Personal Care (1) HCBS In-Home Personal Care (IHPC) are direct services that are authorized using a person-centered planning process that allow an eligible individual the opportunity to direct their services and supports. The direct services assist an in…

410-173-0110 Eligibility for HCBS-In-Home Personal Care (1) To be eligible for IHPC services outlined in these rules, individuals shall: (a) Be eligible for 1915(i) HCBS as outlined in these rules and OAR 410-173-0010; (b) Have assessed needs for ADL’s and IADL’s as documented in…

410-174-0000 Purpose and Scope (1) These rules establish processes and procedures for traditional health workers and the programs and organizations they work for to receive enhanced payment for delivering culturally and linguistically specific physical health related services to …

410-174-0001 Definitions (1) “Culturally and linguistically specific services” means quality health care or health care related services that are designed specifically for a distinct minoritized cultural community, developed based on the languages used and the cultural values of …

410-174-0010 Culturally and Linguistically Specific Services Organization (1) In order to qualify for enhanced payments for culturally and linguistically specific services provided by traditional health workers as an organization, the organization must: (a) Be enrolled as a provi…

410-174-0020 Culturally and Linguistically Specific Services Program Qualifications (1) In order to qualify for enhanced payments for culturally and linguistically specific services provided by traditional health workers as a program, the program must: (a) Be enrolled as a provid…

410-174-0030 Culturally and Linguistically Specific Services Individual Traditional Health Worker Qualifications (1) In order to qualify for enhanced payments for culturally and linguistically specific traditional health worker services, an individual must: (a) Be enrolled as a p…

410-200-0010 Overview. These rules, OAR 410-200-0010 through 410-200-0510, describe eligibility requirements for the Health Systems Division (HSD) Medical Programs. Statutory/Other Authority: ORS 411.402, 411.404 & 413.042 Statutes/Other Implemented: ORS 411.400, 411.402, 411.404…

410-200-0015 General Definitions (1) “Action” means a termination, suspension, denial, or reduction of Medicaid or CHIP eligibility or covered services. (2) “Active renewal” means the renewal process for cases that are not processed via automated renewal wherein a prepopulated re…

410-200-0100 Coordinated Eligibility and Enrollment Process with the Department of Human Services and the Federally Facilitated Marketplace (1) This rule describes the coordination of eligibility and enrollment between the Oregon Health Authority (Authority), the Oregon Departmen…

410-200-0105 Hospital Presumptive Eligibility 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 hospita…

410-200-0110 Application and Renewal Processing and Timeliness Standards (1) General information as it relates to application processing is as follows: (a) An individual may apply for one or more medical programs administered by the Authority, the Department, or the Federally Fac…

410-200-0111 Authorized Representatives (1) With the exception of individuals who are included in the EDG solely because they are part of a tax-filers tax group (see OAR 410-200-0305) and except as limited in sections (3), (4), and (5) of this rule, the following individuals may …

410-200-0115 HSD Medical Programs—Effective Dates (1) This section of the rule identifies the effective date of coverage for new applicants who are approved for HSD Medical Program benefits. (a) For all HSD Medical programs except OHP Bridge - Basic Health Program (see OAR 410-20…

410-200-0120 Notices (1) Except as provided in this rule, the Authority shall send: (a) A basic decision notice whenever an application for HSD Medical Program benefits is approved or denied; (b) A timely continuing benefit decision notice whenever HSD Medical Program benefits ar…

410-200-0125 Acting on Reported Changes (1) When an HSD Medical Program beneficiary or an individual authorized to act on the beneficiary’s behalf reports a change that may affect eligibility, the Agency shall promptly redetermine eligibility before reducing or ending medical ben…

410-200-0130 Retroactive Medical (1) The Authority may evaluate for retroactive medical eligibility for all HSD Medical Programs, except retroactive eligibility for OHP Bridge - Basic Health Program is not permitted. (2) The Authority shall evaluate for retroactive medical eligib…

410-200-0135 Assumed, Continuous, and Protected Eligibility (1) Assumed Eligibility is as described below: (a) A child born to an individual who is eligible for and receiving Medicaid/Children’s Health Insurance Program (CHIP) benefits at the time of the birth is an assumed eligi…

410-200-0140 Eligibility for Residents of a Public Institution (1) A resident of a public institution is not eligible for Health System Division (HSD) Medical Program benefits, except as follows: (a) For individuals residing in an Institution for Mental Disease (IMD), including t…

410-200-0145 Contested Case Hearing (1) For the purposes of this rule, timely means within 90 days of the date the notice of adverse action is received. (2) This rule applies to contested case hearings for programs described in OAR chapter 410 division 200, except for individuals…

410-200-0146 Final Orders, Dismissals and Withdrawals (1) When the Authority refers a contested case under chapter 410 division 200 to the Office of Administrative Hearings (OAH), the Authority must indicate on the referral: (a) Whether the Authority is authorizing a proposed ord…

410-200-0200 Residency Requirements (1) To be eligible for HSD Medical Programs, an individual must be a resident of Oregon. (2) An individual is a resident of Oregon if the individual lives in Oregon except: (a) An individual 21 years of age or older who is placed in a medical f…

410-200-0205 Concurrent and Duplicate Program Benefits (1) An individual receiving HSD Medical Program benefits may not receive the following medical benefits at the same time except as described in section (3) of this rule: (a) Any other HSD Medical Program; (b) Office of Child …

410-200-0210 Requirement to Provide Social Security Number (1) The Agency may collect a Social Security Number (SSN) for the following purposes: (a) The determination of eligibility for benefits. The SSN is used to verify income and other assets and to match with other state and …

410-200-0215 Citizenship and Non-Citizen Status Requirements (1) To meet the citizenship requirement for an HSD Medical Program, an individual must be: (a) A citizen of the United States; or (b) A citizen of Puerto Rico, Guam, the Virgin Islands or Saipan, Tinian, Rota or Pagan o…

410-200-0225 Assignment of Rights 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) As a condition of eligibility…

410-200-0230 Verification (1) Applicants, beneficiaries, or an individual authorized to act on their behalf shall attest to the following information: (a) Age and date of birth; (b) Application for other benefits; (c) Caretaker relative status; (d) Household composition; (e) Lega…

410-200-0235 Changes That Must Be Reported (1) Reporting requirements described in this rule apply to any individual whose information is considered in determining eligibility for any case member. (2) An individual or someone authorized to act on the individual’s behalf shall rep…

410-200-0240 Healthier Oregon and Citizenship Waived Medical and Citizenship Waived Medical Plus Benefits (1) Healthier Oregon: (a) Healthier Oregon benefits include Cover All Kids as of July 1, 2022, and are equal to OHP Plus benefits as defined in OAR 410-120-1210. (b) Effectiv…

410-200-0305 Eligibility Determination Group — Health System Division Medical Programs. (1) When establishing eligibility for MAGI Medicaid/CHIP, each applicant or beneficiary shall have their own Eligibility Determination Group (EDG) determined individually based on the followin…

410-200-0310 Eligibility and Budgeting; Health Systems Division Medical Programs. (1) Eligibility is evaluated by reviewing the financial and non-financial information for the applicable budget months. The budget month is established as follows. (a) For new applicants, the budget…

410-200-0315 Standards and Determining Income Eligibility (1) This rule outlines income thresholds for Health System Division (HSD) Medical Programs. See OAR 410-200-0310 for eligibility and budgeting. (2) The income standard for the Modified Adjusted Gross Income (MAGI) Parent o…

410-200-0400 Specific Requirements; Breast and Cervical Cancer Treatment Program (BCCTP) This rule establishes eligibility criteria for medical assistance based on an individual's need of treatment for breast or cervical cancer, including pre-cancerous conditions (treatment). The…

410-200-0405 Specific Requirements; Substitute Care In addition to eligibility requirements applicable to the Substitute Care program in other rules in chapter 410 division 200, this rule describes specific eligibility requirements for the Substitute Care program, effective 10/01…

410-200-0407 Specific Requirements; Former Foster Care Youth Medical Program This rule describes specific eligibility requirements for the Former Foster Care Youth Program (FFCYM). (1) There is no income test for the FFCYM Program. (2) An individual is eligible for the FFCYM Prog…

410-200-0410 Specific Requirements; MAGI CHIP In addition to eligibility requirements applicable to MAGI CHIP in other rules in chapter 410 division 200, this rule describes specific eligibility requirements for the MAGI CHIP program. (1) Individuals may not be eligible for MAGI …

410-200-0415 Specific Requirements; MAGI Child In addition to eligibility requirements applicable to the MAGI Child program in other rules in chapter 410 division 200, this rule describes specific eligibility requirements for the MAGI Child program. (1) To be eligible for the MAG…